A technology, service or procedure may align precisely with an existing code, or it may be necessary to apply for a new or revised code. Become familiar with the Current Procedural Terminology (CPT®) code set, structure and guidelines to determine whether a code already exists for the procedure or service the product in question enables.
Where to find information on the current CPT code set
The AMA offers a range of coding resources to support the identification and proper use of CPT codes.
These additional resources may be especially helpful for determining whether a code already exists that aligns with the innovation:
- The CPT® Professional Edition codebook is published by the AMA once a year and contains the current, complete set of five-digit CPT codes, descriptors and official guidelines to code medical services and procedures. The introductory materials and explanations of CPT conventions (e.g., semicolon, the indent, “separate procedure,” cross-references, etc.) within CPT Professional Edition may also be helpful resources.
- On CPT® Network, AMA members and CPT Network subscribers can quickly research a database of commonly asked questions and clinical examples (vignettes). If the answer to a specific question cannot be found in the database, authorized users may submit an electronic inquiry—for instance, whether there is an existing CPT code that may fit a technology.
- CPT® Knowledge Base (AMA log in required) is a subscription database of over 4,000 commonly asked coding questions submitted from across the spectrum of specialties and answered by CPT experts. CPT Knowledge Base subscribers may find that their specific use case has already been addressed in one of them.
- Some early release sections of the CPT code set are published as PDFs on the AMA website. For instance, Category III CPT codes and CPT Administrative MAAA codes are released tri-annually, and CPT PLA codes are released quarterly.
In addition to these resources, coverage policies, which are established and published by health insurance payers, for similar technologies may list procedure codes.
Tips for becoming familiar with the CPT code set
- A CPT code is intended to describe procedures and services performed by physicians and other qualified health care professionals (QHPs), or entities.
- The CPT code must accurately describe the procedure or service being performed, rather than approximate that procedure or service.
- CPT codes can describe medical devices generally if they are integral to a procedure or service delivered in the United States and cannot be separately reportable from that procedure or service.
- When identifying an existing code for a procedure or service, all the language within a code descriptor and its associated guidelines should be assessed, including information in the descriptor that may be enclosed in parentheses.
Proposing CPT code updates: New codes vs. revisions to existing codes
You determine that your service or procedure needs to be aligned with a CPT code, but no existing codes accurately describe your service or procedure. Here’s what to consider when deciding between revising a code versus pursuing a new code.
When to propose a new code
Proposing to add a new code to the CPT code set may be the appropriate path if:
- The service or procedure is distinct, and not already reportable by one or more existing CPT codes.
- The service or procedure is not a fragmentation of an existing service.
- The request is not simply an attempt to report unusual effort or extraordinary circumstances associated with a service already in the CPT code set.
When to propose revisions to an existing code
Proposing revisions to an existing CPT code may be the appropriate path if:
- The procedure or service fits an existing code family, but the descriptors or structure no longer reflect current practice.
The medical specialty society that represents the area of medicine you are innovating in may be able to help guide that path. If you submit a code change application for a new code that would be better suited as revisions to an existing code, AMA staff will work with you to update your application as needed. Furthermore, the CPT Editorial Panel reviewers may offer guidance as they review your application once it is submitted.
Submitting a code change application does not ensure that the Panel will adopt your proposed code changes.
If you have questions about the CPT code change application process or requirements, contact: [email protected].
Disclaimer: This information does not supersede specific coding guidance published in the CPT codebook, which is subject to change and further modification by the CPT Editorial Panel. Establishment of a CPT code does not imply approval, endorsement, or sponsorship of the medical procedure or service by the AMA. A CPT code does not guarantee coverage, reimbursement, or payment. The AMA disclaims responsibility for any errors or omissions and for any consequences attributable to or related to any use, reliance, or interpretation of the information herein.
