First, review the AMA CPT and RUC processes.

Second, draft the suggested new code or code revision (due to change in physician work) and indicate why this code addition or revision is necessary to enhance the current coding system. (Please note: code proposals for new technology require FDA approval of the technology and a minimum of two published two-year follow-up studies on the technology, at least one of which must have been conducted by an impartial researcher.)

Third, fax, mail or e-mail the code revision or proposal to NASS:

North American Spine Society Code Proposal Revision
Attn: Kim Kuman
7075 Veterans Blvd
Burr Ridge, IL 60527
Fax: (630) 230-3782
E-mail: Kim Kuman

Code changes are considered on a two-year cycle. A completed proposal must be submitted to the AMA CPT Editorial Panel by the beginning of November 2010 in order for the code change to be included in the 2012 AMA Current Procedural Technology.

Please submit any suggested code changes or additions to NASS by early July in order to get it into the AMA by the November deadline.

Upon receipt of the suggested code addition or revision, NASS’ Coding Committee Co-Chairs, NASS’ AMA CPT Representative, and NASS’ AMA RUC Representative will review the proposal for appropriateness within the AMA coding guidelines and any potential ramifications to the current fee structure within the specialty.

If it is determined that the code change should be pursued, the appropriate NASS committees will develop a consensus proposal within NASS. The consensus proposal is presented to an Ad Hoc Spine Forum of other specialty societies whose members would be affected by this code to garner support and consensus among the specialties. Upon receipt of a complete proposal, AMA CPT Advisors of all specialties are solicited for comments to assist the AMA CPT Editorial Panel  in making the decision.

Once a code is approved by the AMA CPT Editorial Panel, it is forwarded by CPT to the AMA RUC Committee for valuation of physician work. The Relative Value Update Committee (RUC) comprises 29 members. National medical specialty societies appoint 23 of the members. Two of these seats rotate on a two-year basis, with one reserved for an internal medicine subspecialty and one for any other specialty. The RUC Chair, the Co-chair of the Health Care Physician Advisory Committee Review Board (an advisory committee representing non- MD/DO health professionals), and representatives of the AMA, the American Osteopoathic Association and the CPT Editorial Panel hold the remaining six seats.

The Advisory Committee to the RUC comprises a physician representative from each of the 109 specialty societies seated in the AMA House of Delegates. Relative value recommendations are developed by the specialty society whose members provide the service being valued. RUC Advisory Committee members are responsible for presenting their specialties’ recommendations (based on the survey findings of at least 30 completed surveys).

Specialty society members complete a RUC survey to assist in calculating reimbursement for the new (or changed) code(s) which compares the new or revised service(s) to a reference list of existing CPT codes developed by the specialty. The survey is based on a clinical vignette of a typical patient. The specialty society details the physician work involved in the procedure. The survey data are formally presented to the AMA RUC for approval of the recommended relative value units assigned to the specific code(s). These recommendations are forwarded to the Centers for Medicare and Medicaid Services (CMS) in May of each year. The Medicare Physician Payment Fee Schedule includes CMS’ review of the RUC recommendations, and is usually published around November 1 for implementation on January 1 of the following year.

It is important to note that adding codes to CPT does not add funds to Medicare/Medicaid. Any new code’s reimbursement will invariably take an equal amount of reimbursement away from another code within the specialty.

Current Procedural Terminology—Overview

What is CPT?
Physician’s Current Procedural Terminology (CPT) is an up-to-date, comprehensive classification and nomenclature system for accurately identifying procedures and services performed by physicians and other health care professionals. CPT includes more than 8,000 five-digit codes, each assigned to a short and long description of a service or procedure. Other coding systems, like the International Classification of Diseases (ICD-9), describe diagnoses. Still other coding systems, like CMS’s Healthcare Common Procedure Coding System (HCPCS), describe supplies and other ancillary services such as ambulance services.

How is CPT maintained?
CPT is updated annually to ensure that it always reflects the most current and accurate procedural terminology. As new procedures and technologies are introduced to medicine or procedures become obsolete, CPT is reviewed to reflect those changes through an organized and thorough process. The AMA facilitates the maintenance process by subjecting proposals to add, modify and delete codes to critical review. This critical review includes research, consultation and action by AMA coding experts, the CPT/HCPAC Advisory Committee and, ultimately, the CPT Editorial Panel.

Proposals to change CPT
Anyone can request a change to CPT. Most proposals for revisions, additions or deletions to CPT come from medical specialty and other professional societies. Once a proposal is received, AMA staff reviews and works with the requestor should further refinement be necessary. AMA staff then circulates the proposal to the appropriate CPT/HCPAC Advisory Committee members for formal review and comment. Pending favorable advisory input, the issue is placed on the agenda of the CPT Editorial Panel.

CPT Committees
The CPT Advisory Committee is composed of more than 109 physicians and a small group of allied health care professionals that reviews each proposal to change CPT. The Advisory Committee offers its recommendations to the CPT Editorial Panel. Each committee member represents a specialty society and is highly knowledgeable about coding. William Mitchell, MD is the NASS representative to the CPT Advisory Committee.

The CPT Editorial Panel is responsible for maintaining CPT. This panel is authorized to revise, update or modify CPT. The Panel is comprised of 17 members: 12 physicians nominated by the AMA; one physician nominated from the Blue Cross and Blue Shield Association, the Health Insurance Association of America, the American Hospital Association and the Centers for Medicare and Medicaid Services; and the non-physician professional co-chair of the Health Care Professionals Advisory Committee.

Changes made
Once the CPT Editorial Panel votes on changes to CPT, AMA staff develops and incorporates the year’s changes into the annual edition of CPT. (Changes requiring a new or review of a relative value are referred to the Relative Value Update Committee). AMA staff also participate in educating physicians and health information professionals about the changes by printing an annual tabular update, preparing the CPT Coding Symposium, the CPT Changes: An Insider’s View and other educational resources.

Relative Value Update Committee (RUC)—Overview

Overview of Entire Process

When a new code is introduced through the Physician’s Current Procedural Terminology (CPT) process, a RUC survey is completed by the interested specialty society members to assist in determining the work value of the new code. This survey includes a vignette that describes the specific work involved in performing the procedure and requires physicians to determine the amount of work involved in performing the service. The result of this survey is a major basis for proposing a relative value unit (work value), or reimbursement amount to the code. Whatever services are included in the RUC survey vignette for a given CPT code are considered bundled.

The recommended work relative value units (RVUs) are presented to the RUC for approval. Since all monies are derived from one Medicare/Medicaid government fund through CMS and it is often a “zero-sum” game, this can be a challenge.

The Advisory Committee to the RUC is composed of a physician representative appointed from each of the 109 specialty societies seated in the AMA House of Delegates.  William Sullivan, MD is NASS’ RUC Representative. Relative value recommendations are initially developed by the specialty society whose members provide the service being valued via a survey process. RUC Advisory Committee members are responsible for presenting their specialties’ recommendations, which are based on the surveys performed, to the RUC.

The HCPCS System

The HCPCS Level II National Codes found in HCPCS 2010 include over 4,000 codes and represent just one part of a larger, three-level coding system called HCPCS.

HCPCS (pronounced “hick-picks”) is the acronym for the Centers for Medicare and Medicaid Services (CMS) Health Care Common Procedure Coding System. This system is a uniform method for health care providers and medical suppliers to report professional services, procedures and supplies. CMS developed this system in 1983 to:

• Meet the operational needs of Medicare/Medicaid.
• Coordinate government programs by uniform application of CMS policies.
• Allow providers and suppliers to communicate their services in a consistent manner.
• Ensure the validity of profiles and fee schedules through standardized coding.
• Enhance medical education and research by providing a vehicle for local, regional, and national utilization comparisons.

HCPCS Levels of Codes
Each of the three HCPCS levels is its own unique coding system. Levels I and II are also known by the names shown here with the level numbers. Level III codes or local codes will be discontinued.

Level I – CPT
Level I is the American Medical Association’s Physicians’ Current Procedural Terminology (CPT) codes. For more information, please refer to Introductory Section, Page iv.

Level II – HCPCS/National Codes
CPT does not contain all the codes needed to report medical services and supplies, and CMS developed the second level of codes – those found in the American Medical Association’s Medicare’s National Level II Codes HCPCS 2009.

The HCPCS codes begin with a single letter (A through V) followed by four numeric digits. They are grouped by the type of service or supply they represent and are updated annually by CMS.

HCPCS/National codes are now required for reporting most medical services and supplies provided to Medicare and Medicaid patients. An increasing number of private insurance carriers are also encouraging or requiring the use of HCPCS/National codes.
 

Level III – Local Codes

The HCPCS Level III codes are just one part of a larger three-level coding system that became a two-level coding system. The Health Insurance Portability and Accountability Act (HIPAA) required that there be standardized procedure coding. To meet this requirement, all unapproved HCPCS Level III codes were eliminated on December 31, 2003.

To compensate for the loss in local reporting, a greater number of codes are available on the national level. For example, since 2000 there has been a 47 percent increase in the number of Level II codes, owing in part to the increasing number of codes.
 

Modifiers
Modifiers should, or in some cases must, be used to identify circumstances that alter or enhance the description of a service or supply.

Level I (CPT) modifiers are two numeric digits (eg, -26 - Professional Component) and are described in detail in Appendix of the AMA CPT book. They are also maintained and updated
on an annual basis by the AMA.

Level II (HCPCS/National) modifiers are either alpha numeric or two alphabetic digits (AA-VP) (eg, TC – Technical Component). They are recognized by carriers nationally and are updated annually by CMS.

—— Source: American Medical Association’s Medicare’s National Level II Codes HCPCS 2009