empowering physicians to deliver the best patient care slides courtesy of: richard w. waguespack,...

EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE

Slides courtesy of: Richard W. Waguespack, MD, FACSPresident Elect, AAO-HNS, Former CPT Editorial Panelist, CPT

Advisor for the Triological Society, Past Coordinator for Socioeconomic Affairs


Members should understand:

•Manner by which CPT codes are created and modified by the AMA

•Role of the AAO-HNS in the process

•Rudiments of bundling/code edits

CPT Process


• The CPT code set has been developed, owned, and maintained by AMA since 1966

• Is the national standard for electronic reporting of health care information relating to physician services, designated in the final rule for HIPAA August 17, 2000

• The code set is maintained by the AMA CPT Editorial Panel

Current Procedural Terminology (CPT)


• A total of 17 members – 11 physicians nominated by Medical Societies plus one member each from:

• Blue Cross Blue Shield Association (BCBSA)• America’s Health Insurance Plans (AHIP)• American Hospital Association• Center for Medicare and Medicaid Services (CMS)• 2 seats for members of Health Care Professional Advisory

Committee (HCPAC)

CPT Editorial Panel


• Editorial Panel Chair

• Co-Chair (serves as Chair of CPT Assistant Editorial Board)

• Three Members-At-Large elected by entire Panel (one must be a third-party payer representative)

CPT Editorial Panel Executive Committee


• Support the Editorial Panel

• Nominated by national medical specialty societies that are represented in the AMA House of Delegates and AMA HCPAC

• Serve to give specialty-specific advice on coding and nomenclature to Editorial Panel

• Give support to CPT staff, suggest revisions, review and promote education of membership on use of CPT

• Otolaryngology is represented by CPT Advisors from the AAO-HNS, Triological Society, AAOA, and AAFPRS

CPT Advisors’ Role

CPT Advisors


• Category I• “Standard codes” but does not “guarantee” carrier

payment• Higher threshold of usage, literature support,

standard of care

• Category III• New technology and less literature support• May be used for tracking• FDA approval not required • Not valued by RUC but may be paid by carriers

• Unlisted and Category II codes

Types of Codes: Category I or III?


Who can propose a new or request modifying an existing CPT code?

• Individual person or institution• Specialty society• AMA CPT Editorial Panel members or staff• Medical device or drug company• Payer (commercial or governmental)• RUC (AMA Relative Value Update CMTE)

CPT Development


• Who can propose or modify a CPT code?

• Individual person or institution• Specialty society• AMA CPT staff• Medical device or drug company• Payer, commercial or governmental

The CPT Process


• Who as an Otolaryngologist can request a new or revised CPT Code?• Individual AAO-HNS member• AAO-HNS standing committees, (e.g., Sleep Disorders, Rhinology

Paranasal Sinus)• Medical device or drug company• Subspecialty society, (e.g. AAOA (Serial Endpoint Titration Editorial

Change)) or others, (e.g. ASHA (cochlear implant programming codes))

• Requests for code changes or revaluation must be reviewed by the New Technology Pathway.

Academy CPT Development


Academy Review: New Technology Pathway

Academy Staff Intake of inquiry

Medical Device and Drug Committee (MDDC)• Assess safety, efficacy, and adoption of new technology

Board

3P (Physician Payment Policy Workgroup)• Initial evaluation and communication to inquiring party, Academy staff, and 3P group – James C. Denneny, III, M.D., Socioeconomic Coordinator.• Assess appropriate coding based on committee input, CPT literature criteria, CPT code descriptors, and RUC database descriptors• Provide input and guidance for progression of -99 and Category III codes to Category I

•Lead the CPT process including creation and presentation of CCPs•Lead the RUC process including creation, administration, and presentation of surveys

Academy Committees• Provide information as needed to MDDC, CPT/RVU Committee, and 3P to make informed assessments

Health Policy Report/3P Board representatives Updates

CPT/RVU committee

• Assists 3P as needed with their processes


If only the rest were this straight-forward...

CPT Development


CPT is a reporting system; code edits and bundling are reimbursement policies imposed by payers

Some edits are embedded in CPT• CPT terminology “(separate procedure)”

• A separate procedure is one that should not be separately reported if part of a larger service, eg, tracheostomy with total laryngectomy

• Pay Close Attention to Parentheticals (“Do not report… or Report… with….”)

• These parentheticals list codes that either should, or should not, be reported with other codes.

Bundling is a 4-Letter word


National Correct Coding Initiative (NCCI) forMedicare

• Developed by Correct Coding Solutions LLC and adopted with approval of CMS.

• Developed quarterly and specialty society input is sought (the Academy is very active in this process).

• May be revised after issuance with clinical support.• Often adopted by commercial carriers but beware of carriers that “cherry

pick” edits, global periods, etc.• NCDs/LCDs (National/Local carrier determinations).

Contact Health Policy staff for assistance locating this information: [email protected]

NCCI Edits

empowering physicians to deliver the best patient care slides courtesy of: richard w. waguespack,...

Documents

best patient care cpt

cpt codes

empowering physicians

cpt editorial panelist

cpt code descriptors

cpt code set

revised cpt code

existing cpt code