Slides courtesy of : Richard W. Waguespack, MD, FACS

1. Quality|Advocacy|Specialty 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

2. CPT Process 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

3. Current Procedural Terminology (CPT) • 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

4. CPT Editorial Panel • 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)

5. CPT Editorial Panel Executive Committee • 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)

6. CPT Advisors’ Role CPT Advisors • 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

7. Types of Codes: Category I or III? • 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

8. CPT Development • 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)

9. The CPT Process • 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

10. The CPT Process • 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

11. Academy CPT Development • 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.

12. Academy Review: New Technology Pathway Academy Staff Intake of inquiry Board Health Policy Report/3P Board representatives Updates • 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 • Medical Device and Drug Committee (MDDC) • Assess safety, efficacy, and adoption of new technology • CPT/RVU committee • Assists 3P as needed with their processes • Academy Committees • Provide information as needed to MDDC, CPT/RVU Committee, and 3P to make informed assessments

13. CPT Development If only the rest were this straight-forward...

14. Bundling is a 4-Letter word • 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.

15. NCCI Edits • 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: healthpolicy@entnet.org