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EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE Slides courtesy of: Richard W. Waguespack, MD, FACS President Elect, AAO-HNS, Former CPT Editorial.

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Presentation on theme: "EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE Slides courtesy of: Richard W. Waguespack, MD, FACS President Elect, AAO-HNS, Former CPT Editorial."— Presentation transcript:

1 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE Slides courtesy of: Richard W. Waguespack, MD, FACS President Elect, AAO-HNS, Former CPT Editorial Panelist, CPT Advisor for the Triological Society, Past Coordinator for Socioeconomic Affairs Quality | Advocacy | Specialty

2 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE 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

3 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE 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)

4 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE A total of 17 members – 11 physicians nominated by Medical Societies plus one member each from: Blue Cross Blue Shield Association (BCBSA) Americas 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

5 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE 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

6 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE 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

7 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE 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?

8 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE 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

9 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE 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

10 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE 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

11 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE 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

12 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE 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

13 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE If only the rest were this straight-forward... CPT Development

14 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE 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

15 EMPOWERING PHYSICIANS TO DELIVER THE BEST PATIENT CARE National Correct Coding Initiative (NCCI) for Medicare 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: NCCI Edits


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