The digital health environment is changing at a rapid clip with amazing advances in augmented intelligence (AI), telehealth and other tools for treating patients remotely or virtually leading the way.
One constant in this landscape has been the Current Procedural Terminology (CPT®) code set, which continues to evolve to keep pace with the innovations that promise to improve patient care while reducing burnout-inducing administrative burdens for physicians and their practices.
Dispelling myths about CPT codes
Speaking during a panel at the ViVE health IT conference in Los Angeles earlier this year, Lori Prestesater, American Medical Association (AMA) senior vice president of health solutions started by “dispelling myths” that the CPT code set is merely a tool for fee-for-service payments and that the CPT Editorial Panel’s work is shrouded in secrecy.
“CPT codes are a path to payment, but they do not define payment—that's a common myth that people have,” Prestesater said.
“CPT codes are not just a mechanism for fee-for-service billing—they are a foundational way ... to define procedures and services provided by physicians and other qualified health professionals,” she added. “No matter what model of payment you're using, you still have to define and account for the care provided.”
Another myth is that the AMA defines the codes. While the 21 volunteer physician and other qualified health care professional members of the CPT Editorial Panel (the Panel) are appointed by the AMA Board of Trustees, the CPT code development process is independent, open and transparent. The CPT Editorial Panel makes independent decisions and is supported by over 200 advisers who are nominated by specialty societies.
Medical specialties are represented as are health plans, coders and government agencies. The Centers for Medicare & Medicaid Services (CMS) has an advisory role on the Panel, and Prestesater said that advisory seats were recently added for representatives from the Food and Drug Administration and the Centers for Disease Control and Prevention.
From AI implementation to EHR adoption and usability, the AMA is making technology work for physicians, ensuring that it is an asset to physicians—not a burden.
The code set continues to evolve
Noting that “the code set will continue to evolve,” Prestesater described how the CPT Editorial Panel added new codes in 2019 to support remote physiologic monitoring (RPM).
While CPT codes for RPM are now in common use, “at the time, those were innovative and forward looking,” she said.
“Then, as the pandemic hit, we moved forward and digital care evolved, and we added a second set of codes in 2022 to support remote therapeutic monitoring [RTM],” Prestesater said.
The new codes “offered a broader reach” and “provided the foundation for reporting models of care that hadn't been implemented before.”
RPM tools assess data to appropriately manage diseases related to physiologic parameters, while RTM tools expand access to remote monitoring and monitoring of data related to signs, symptoms and functions of a therapeutic response. As adoption of new technologies increases, these codes will continue to be evolve as the Panel considers new and refined use cases.
Citing the CPT taxonomy for classifying medical services powered by AI, which is often called “artificial intelligence,” Prestesater said that the AMA is working with several federal agencies, including CMS, as well as industry stakeholders to provide standardized terminology for medical devices using AI.
“We need to really lean into innovation so that we can support whatever kind of models evolve that provide the right and best patient care,” she said.
The CPT code set serves as an information engine
CPT codes “play a foundational, continued role” in research and testing of new payment models (PDF), Prestesater said.
Fellow panelist, Lucia Savage, is chief privacy and regulatory officer for Omada Health, which offers a National Diabetes Prevention Program (National DPP) lifestyle-change program. Savage noted that Omada worked with the CPT Editorial Panel, YMCA and others to develop a new code for in-person and virtual National DPPs.
“We renewed the code in 2021 and, much to our surprise, many other people were also using this code at quite a high volume—so that was very gratifying,” Savage said, noting the important role the code played in advancing National DPPs.
“If we don't categorize the care properly under the CPT [code set], then we cannot analyze if the care is efficacious,” she explained.
The CPT code set provided the “information engine” that allowed for such an analysis, Savage said.
The CPT Editorial Panel process for ensuring that the CPT code set reflects the coding and data-driven demands of a modern health care system is open and transparent, Prestesater said. Anyone can attend an Editorial Panel meeting and anyone can submit a code-change request.
The CPT Editorial Panel will meet next Sept. 19–21, in Albuquerque, New Mexico.
