An Inside Look at How the CPT Is Kept Balanced and Current

Suppose that a new otolaryngology-related coding change has been approved by the CPT editorial panel and is undergoing valuation by the AMA-appointed medical specialty delegates in the RUC panel. What happens next? 

“The family of existing codes, in addition to the new code, are opened for valuation or revaluation. The RUC advisory team from otolaryngology creates very granular surveys to be filled out by otolaryngologists regarding the technical difficulty, stress caused, risks involved, and, most importantly, time spent on the procedures performed,” Dr. Lin explained. “The older an existing procedure is, in general, the faster otolaryngologists become at performing it. So, when an older code is surveyed for revaluation, the time and difficulty of the procedure, by its nature, will also have decreased, in addition to the budget-neutral dilution of values. We may want to have new codes to describe cochlear implant removal or Draf procedures, but is it worth the risk of valuation to the older ones? That’s the big question.”

Navigating the coding system is especially challenging for physicians who aren’t yet trained in CPT code reporting. “Newer physicians will often report several codes that have overlapping work for a given procedure, and there are rules as to what codes may be reported together,” Dr. Lin said. “A classic example is reporting the use of the operating microscope for a tympanoplasty. A typical tympanoplasty uses some sort of magnification, traditionally microscopic, but that now includes endoscopic. Because of what’s typical for tympanoplasty, you don’t report use of an operating microscope separately.”

The reporting of novel procedures is another tricky area, such as when providers attempt to submit them under an established code. Dr. Lin pointed to the use of absorbable nasal implants to repair nasal valve collapse using the pre-existing spreader or batten graft code, when the amount of work performed in each procedure is very different. “When the use of existing codes for ‘squeezing in’ new or different procedures becomes more widespread, this increase in code use is picked up by AMA screens,” he said. “This may lead to undesirable results and, eventually, the devaluation of the pre-existing codes.” This devaluation is why, as appealing as unlimited expansion of CPT codes may sound, the ultimate effect could prove detrimental.

On the other hand, there are times when new codes are justifiable and needed, said Dr. Lin, referring to his earlier example: “We described the placement of absorbable nasal implants as a new technology procedure with FDA approval and supplied literature support to describe its efficacy,” he said. “We also argued that use of that procedure was consistent with the prevalence of nasal valve collapse. With these criteria fulfilled, we were able to get a novel code for placement of the implant for nasal valve collapse.”