CPT Code Development and Valuation
Developing and valuing CPT codes involves cooperation and planning between HRS, other specialty societies, industry partners, interested parties, the American Medical Association's CPT Editorial Panel and the AMA/Specialty Society Relative Value Scale Update Committee (RUC).
HRS and CPT Code Development
As a member of the CPT Editorial Panel’s Advisory Committee, HRS can submit applications to the Panel, comment on code change applications and provide clarifications to the Panel about appropriate code usage to electrophysiology services.
The Society works with specialty organizations, manufacturers and other interested parties to develop applications for new or revised services. In addition, HRS has worked with manufacturers to assist in determining the optimal timing for submitting a code request.
Category I and Category III Codes
Category I codes are for established services, or FDA-approved procedures. The time required to approve, value and publish a new code can span two years.
Category III codes, for emerging technologies, typically are implemented within one year or sooner. Category III codes, which typically are used for tracking purposes, can be used for up to five years while the new service still is undergoing studies. They are not usually payable though sometimes Medicare or other insurers will pay for them.
As an example, when leadless pacemaker services were still being studied, the procedures were identified via Category III CPT codes. Following the FDA’s approval of the device, Medicare began to cover the services even though they still were billed via the Category III codes. This decision was due to the device’s benefits and the time that the CPT approval, code valuation and publication process.
For more information, about the CPT Process, visit https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval
HRS and Code Valuations
The AMA/Specialty Society Relative Value Scale Update Committee (RUC) recommends physician work relative value units (RVUs) and the inputs required to assess Practice Expense RVUs. When a new Category I CPT code is approved, or an existing code has not been re-valued in a long time, HRS works with other relevant specialties and the RUC to develop those recommendations.
Once a new CPT code is approved, it must be assigned relative value units (RVUs) for use in setting its Medicare payment level.
For example, using hypothetical RVUs for the sake of straight-forward comparisons:
If a certain device implant requires 60 minutes of intra-service time and three visits during the global period that are equal to a 99213 office visit.
We seek comparator codes in the same and other specialties that have similar inputs. Then, we compare the intensity and complexity of the typical patient and the service. Based on those factors, we will recommend a work RVU that is higher, lower, or the same as the comparator code.
For the Practice Expense RVUs, we provide only the clinical staff type, the number of minutes that staff spend providing the service, and the costs of equipment and supplies. Those data also are reviewed by the RUC. Then those inputs are submitted to CMS and applied to the formula for computing practice expense RVUs.
For more information about the RUC, visit https://www.ama-assn.org/about/rvs-update-committee-ruc/rvs-update-committee-ruc
If you have received a request to complete a RUC survey, this video explains the survey's purpose and steps to complete it. For additional information, please contact HRS' Senior Director, Health Policy and Reimbursement, Lisa Miller at [email protected].