Who Is The Driving Force Behind The CPT Medical Code Set

by  Find-A-Code™
Sep 11th, 2022

The U.S. healthcare system relies on hundreds of thousands of medical codes to facilitate administration and billing. The codes are divided into different sets, each of which is developed and maintained by a separate entity. Take the Current Procedural Terminology (CPT) code set. The driving force behind it is the American Medical Association (AMA).

The CPT code set is arguably the most utilized code set in this country. Its codes cover procedures and services provided by all sorts of healthcare organizations. They are utilized by primary care offices, specialists, labs, diagnostic testing facilities, etc.

Medical coders rely on their own familiarity with the CPT set to accurately assign codes for billing purposes. Billing specialists also need to understand the set so that they can prepare bills accurately. Accurate bills make insurance companies happy and facilitate faster payment.

CPT 2021 Is the Standard

The current standard for this particular code set is known as CPT 2021. As for how long the set has been utilized, its history dates to a handbook first published by the AMA way back in 1962. The AMA actually began working on the handbook two years earlier.

Prior to CPT, medical coding relied on two separate data sets: the Standard Nomenclature of Diseases and Operations (SNDO) and the International Classification of Diseases (ICD). The AMA's position was to develop a new standard that combined both. That is what CPT accomplished.

An Evolving Code Set

As you might expect, the CPT code set is always evolving. With every passing year there are new procedures and services being offered. Existing procedures and services are improved. Constant changes within the scope of healthcare delivery forces CPT to continually adapt.

The AMA still controls the CPT set. Routine code set updates are the domain of the CPT Editorial Panel. This panel is an independent group of experts from throughout the healthcare sector. They review all code changes and updates to make sure certain criteria are met. Any and all changes must meet evidence-based standards to be approved.

According to the AMA, the CPT Editorial Panel doesn't work in isolation. They are supported by a secondary group known as CPT Advisors. These are physicians from a variety of specialties, all considered clinical experts in their fields. Their main task is to propose revisions to the code set based on their knowledge of the current state of healthcare.

Changes Aren't Made Lightly

The CPT code set is a complex and detailed entity, so to speak. Though it does not have a life of its own, it can sometimes seem that way. Getting bogged down in looking up and assigning the right CPT codes can make coders feel like they are battling a monster. All of this is to say that changes to the code set are not taken lightly.

CPT is an evidenced-based code set. That means CPT Advisors need to provide evidence that proposed changes are necessary and beneficial. The Editorial Panel is tasked with reviewing that evidence before rendering a decision. Suffice it to say that affecting changes in the code set isn't easy. It takes time and effort to get changes through.

Every medical code set is governed by unique policies and rules. Each set has its own governing authority responsible for maintaining it. For the CPT code set, that governing authority is the AMA. They originally developed the code set to standardize medical coding across every aspect of healthcare. They continue to maintain the set even as healthcare delivery evolves. It is no wonder the code set is so complex.