CPT: Who are they, and why are they doing this to me?

By Alexander Miller, MD, FAAD, AAD Representative to AMA CPT Advisory Committee, June 1, 2022

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Do you bill insurers electronically for your dermatology medical services and procedures? If so, then you must be familiar with Common Procedural Terminology (CPT) numeric and alphanumeric codes that are required for reporting our services to insurers. You may wonder how these codes originate and why they are occasionally changed, augmented, and redefined, at times seemingly, to disrupt our sense of billing stability. Wonder no more! Read further and you will discover how and why the CPT code set evolves and who are the people behind the action.

The CPT Editorial Panel, composed of physicians from national medical specialty societies and other medical professionals, with input from CMS, is tasked with maintaining the CPT code set. This group works with stakeholders to shape an ever-evolving CPT. They depend upon us, the AMA CPT Advisory Committee members, for guidance and feedback.

Each specialty society that has a seat at the AMA House of Delegates gains the right to nominate Primary and Alternates to the AMA CPT Advisory Committee.

We dermatologists are fortunate to be amply represented by the American Academy of Dermatology (AAD), American Society for Dermatologic Surgery/Association (ASDS/A), American College of Mohs Surgery (ACMS), and the Society of Investigative Dermatology (SID). We work as a team to help shape and/or prevent disruption of the CPT code set. We meet three times a year for 3–4 days meetings, extracting us from our practices into the CPT meeting milieu, where code change proposals are presented, discussed, approved, rejected, or remanded for more work and future reconsideration. Your CPT team works in tandem with our dermatology RVS Update Committee (RUC). The CPT group is charged with securing CPT codes essential for reporting our services to insurers, and the RUC team labors to establish relative values for each CPT code.

How and why are new CPT codes produced and existing codes occasionally redefined? Are sneaky connivers scheming how to best upchuck the CPT to expand their egos? Not at all! We may be happy with the status quo, but as medicine evolves the CPT must keep up by providing accurate avenues for reporting new or modified care paradigms, procedures, and tests. Dermatology is included in this evolution. Your dermatology CPT team takes on many tasks during this process. The impetus for new or revised CPT codes may germinate from a variety of sources. The AMA CPT Editorial Panel, the AMA RVS Update Committee (AMA RUC), or our dermatology RUC team may direct our specialty to propose new codes or to modify the definitions of existing codes to better specify physician/qualified health care professional (QHP) work. A dermatology or other professional specialty society, a group, an individual, or a representative of industry may propose a CPT change affecting dermatology. This initiates continuous, interactive involvement of your CPT team during the entire proposed code formation or modification process. If an action directive comes from the Editorial Panel or the RUC, we must work to fulfill their wishes. When other sources propose new CPT codes or modifications, we as a team thoroughly evaluate the merits of such a proposal, sometimes dousing the prospective applicant with a vinegar of reality that rapidly truncates their initiative, at other times joining with them to mold a reasonable code change proposal to submit to the Editorial Panel. This process may take many months, multiple stages of back-and-forth interaction between the applicant(s) and our CPT team, conference calls, and continued changes to a fluid Code Change Application before it is submitted for evaluation by the CPT staff and the Editorial Panel.

We function in an interactive, complex environment. The CPT Editorial Panel is the sun powering the solar system of Advisors, the planets, which in turn are influenced and pulled by the moons — our dermatology constituents and other interested parties. What happens on one planet may affect the positions of others, and this requires maintaining a constant, delicate balance by way of diplomatic, constructive interactions with other specialties. Occasionally, a disruptive asteroid may threaten our world, and we must effectively identify it and deflect it.

Argh! Why did “they” mess with the intermediate and complex repair codes? Let’s follow this example of the CPT process. In October 2015, the RUC recommended that an AMA CPT Assistant article be generated to specify the clinical and reporting requirements for reporting complex repairs, as there was very high utilization of the complex repair codes. Your dermatology advisors wrote an article for publication in 2016. This article was not accepted, as it could not provide a clear line of differentiation between intermediate and complex repairs based upon extent of undermining. As such, a bright-line guidance did not exist in the CPT. We were consequently tasked with generating a Code Change Application to the CPT Editorial Panel, which instructed us to quantifiably specify the difference between the extent of undermining qualifying for complex versus intermediate repair. After numerous emails, conference calls among ourselves, and on-site discussions with colleagues in other interested specialty societies, we submitted an application in early 2018. This was not accepted by the Panel, and we were directed to further work with our interested specialty colleagues on a revised submission. The resulting document, delivered to the Panel in late 2018, was remanded for on-site modification with input from all specialties with a significant stake in these codes. We were literally collected into a large conference room and admonished to work it out among ourselves to produce a document acceptable to all by the end of the hour. Intense, interactive negotiation led to what you have today: a concise, measurable distinction between intermediate and complex repairs along with additional criteria acceptable to all negotiating parties involved, and to the CPT Editorial Panel reviewers. The Editorial Panel then queried our Advisors “at the table” on the nuances of our collective proposal. This final step requires intense attention and precision on our part, as our answers to questions must be clear, informative, and reliable for our application to succeed. Success! Code Change Application accepted. Our work on this project did not end here, as we were asked to write a CPT Assistant article explaining the distinctions between intermediate and complex repairs, including an illustration of extensive undermining that was incorporated into the CPT manual. What is the CPT Assistant? It is an official AMA publication, available by paid subscription, that expands upon and illustrates CPT coding parameters and processes.

Have you ever wondered why for years skin biopsies were defined by only two codes, one for the initial biopsy, and another for each additional one, without differentiating between the depth or the biopsy technique? There is a difference between the work and technique inherent in superficial versus deep biopsies and shave versus punch versus incisional biopsies that was not captured in the universal biopsy definitions. Your CPT team was tasked with coordinating a restructuring of the biopsy codes that, after a year of discussions and modifications during and between CPT meetings, culminated in a logical transition to new technique-specific biopsy codes. Your Advisors team coordinated the production of clear illustrations of the individual biopsy techniques and depths for the CPT manual, and, working with the Editorial Panel and staff, generated concise descriptive introductory language for the biopsy codes. The process may seem slow and deliberate, but the results must be logical and useful.

But wait, there’s more! Between CPT meetings your CPT Advisors counsel parties interested in submitting Code Change Applications affecting dermatology, discuss and provide position recommendations on dermatology-pertinent Code Change Applications sponsored by other specialties or parties, work with other specialties on CPT Assistant articles of mutual impact, and write/edit DermWorld Question of the Week coding challenges.

Every modification of, or addition to, the CPT code set is a consequence of circumstances that require careful evaluation, coordination with all interested parties, and action. Sometimes such actions lead to no change, when that is best, or to changes when such are needed. Your AMA CPT Advisors work for you, our constituents, to maintain a CPT code set that is current, concise, and useful.

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