Medical Codes: Where Doctors Fit Into Creating New Codes

Have you ever wondered how the thousands of medical codes that billers use everyday are created? How about why there are so many medical codes for seemingly similar ailments? Medical coding has ballooned as new treatments have becomes available, and the new ICD-10 codes go live in October. So, what process determines that new codes be made?

First, the American Medical Association (AMA) created Current Procedural Terminology, or CPT. CPT allows physicians to remain integrally involved in the creation of new medical codes. This system also ensures uniform terminology across fields for complicated procedures, tests and services.

This list is managed by a group of 17 experts that are members of the CPT Editorial Panel. Advised by doctors, device manufacturers, diagnostic test developers and association advisors, this panel keeps an up-to-date list. Three times a year, the CPT Editorial Panel holds a meeting, open to anyone who wishes to attend, at which they discuss code changes. Code change applications are always accepted and these meetings allow those who have submitted a change an opportunity to speak directly to the panel about the changes. Once a change has been vetted by the panel, it is voted upon. These meetings are generally attended by close to 300 members of the medical field.

As the panel approves a new code, or adjusts an old one, the Center for Medicare and Medicaid Services, or CMS, sets a value for that medical code. This value is what determines payment for a service under Medicare. Physicians have a hand in this process as well. A volunteer group of 31 members of the medical community called the Relative Value Scale Update Committee, or RUC, meets three times a year, shortly after the CPT meetings to help discuss the relative value of new codes. Specialty societies will inquire with their members about codes and make recommendations to the RUC to be considered. RUC plays an advisory role to CMS but can also be consulted if the CMS has a question or would like further review of new or updated codes. RUC is tasked with determining if a code is undervalued, overvalued or seemingly correct.

Both the CPT and RUC meetings allow medical professionals to stay involved in the code creation process. From adjusting for new medical developments to ensuring new techniques are included in a timely manner, the AMA works to ensure new codes are useful for all involved in the process.

With changes to medical codes happening 3 times a year, professional billers must stay ahead of the curve and monitor any changes that may affect a practice they work for to ensure changes do not result in claim denial. If you’re worried your current billing system is not up to date, consider hiring Billing Advantage to handle your billing needs. We employ billing experts who stay current with all new medical codes and are able to provide an increase in your accounts paid. To learn how the process of transitioning to billing services from Billing Advantage, visit our How it Works page.