Current Procedural Terminology


The Current Procedural Terminology code set is a procedural code set developed by the American Medical Association. It is maintained by the CPT Editorial Panel. The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. New editions are released each October, with CPT 2021 being in use since October 2021. It is available in both a standard edition and a professional edition.
CPT coding is similar to ICD-10-CM coding, except that it identifies the services rendered, rather than the diagnosis on the claim. Whilst the ICD-10-PCS codes also contains procedure codes, those are only used in the inpatient setting.
CPT is identified by the Centers for Medicare and Medicaid Services as Level 1 of the Healthcare Common Procedure Coding System. Although its use has become federally regulated, the CPT's copyright has not entered the public domain. Users of the CPT code set must pay license fees to the AMA.

History

As the AMA decided in April 1960, the Current Medical Terminology handbook was first published in June 1962 – 1963 to standardize terminology of the Standard Nomenclature of Diseases and Operations and International Classification of Diseases, and for the analysis of patient records, and was aided by an IBM computer. Procedural information was dropped in the transition from the SNDO to CMT, but was released separately as the Current Procedural Terminology in 1966.
The CPT code revisions in 2013 were part of a periodic five-year review of codes. Some psychotherapy codes changed numbers, for example 90806 changed to 90834 for individual psychotherapy of a similar duration. Add-on codes were created for the complexity of communication about procedures. Family therapy and psychological testing codes were among those that were unchanged.

Types of code

There are three types of CPT code: Category I, Category II, and Category III.

Category I

Category I CPT Code. There are six main sections:

Medicare specific codes (HCPCS) for Preventive evaluation and management

CPT II codes describe clinical components usually included in evaluation and management of clinical services and are not associated with any relative value. Category II codes are reviewed by the Performance Measures Advisory Group, an advisory body to the CPT Editorial Panel and the CPT/HCPAC Advisory Committee. The PMAG is composed of performance measurement experts representing the Agency for Healthcare Research and Quality, the American Medical Association, the Centers for Medicare and Medicaid Services, the Joint Commission on Accreditation of Healthcare Organizations, the National Committee for Quality Assurance and the Physician Consortium for Performance Improvement. The PMAG may seek additional expertise and/or input from other national health care organizations, as necessary, for the development of Category II codes. These may include national medical specialty societies, other national health care professional associations, accrediting bodies and federal regulatory agencies.
Category II codes make use of an alphabetical character as the 5th character in the string. These digits are not intended to reflect the placement of the code in the regular part of the CPT codebook. Appendix H in CPT section contains information about performance measurement exclusion of modifiers, measures, and the measures' source. Currently there are 11 Category II codes. They are:
  • Composite measures
  • Patient management
  • Patient history
  • Physical examination
  • Diagnostic/screening processes or results
  • Therapeutic, preventive or other interventions
  • Follow-up or other outcomes
  • Patient safety
  • Structural measures
  • Non-measure claims-based reporting
CPT II codes are billed in the procedure code field, just as CPT Category I codes are billed. Because CPT II codes are not associated with any relative value, they are billed with a $0.00 billable charge amount.

Category III

  • Category III CPT Code – Emerging technology

    Criticism of copyright

CPT is a registered trademark of the American Medical Association and its largest single source of income. The AMA holds the copyright for the CPT coding system. However, in Practice Management v. American Medical Association the U.S. Court of Appeals for the Ninth Circuit held that while the AMA owned the copyright, it could not enjoin a competitor on the basis that the AMA had misused its copyright. Practice Management had argued that the publication of the CPT into federal regulation invalidated the copyright; the general debate around copyright and regulation access was revived in 2012 by a petition motivated by an Administrative Conference of the United States recommendation.
In 2001, Senate Minority Leader Trent Lott criticized what he labeled as the AMA's "monopoly" over the CPT codes for preventing "comparison shopping" by patients and for contributing to rising healthcare costs.
Despite the copyrighted nature of the CPT code sets, the use of the code is mandated by almost all health insurance payment and information systems, including the Centers for Medicare and Medicaid Services, and the data for the code sets appears in the Federal Register. It is necessary for most users of the CPT code to pay license fees for access to the code.
In the past, AMA offered a limited search of the CPT manual for personal, non-commercial use on its website. CPT codes can be looked up on the AAPC website.