Overview of CPT Codes and RUC Process
The basis for all physician reimbursement is the CPT code. CPT codes are the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs. They are used in claims processing and in the payment of medical claims. CPT codes can be found in the CPT Manual, a copyrighted publication, maintained and published by the American Medical Association (AMA). In 1983, CPT was adopted by the Centers for Medicare and Medicaid Services (CMS) and has subsequently been adopted nationwide for both government and commercial insurers. (Source: AUA)
Adding New Codes
Applications for new CPT Codes must follow specific steps as defined by the AMA.
Step 1: Review by Specialty Societies:
Within urogynecology, requests for new codes must be submitted to either the AUGS Coding and Reimbursement Committee, the AUA Coding and Reimbursement Committee (CRC), or the ACOG Committee on Health Economics and Coding (CHEC) depending on the nature of the code. Applications may be submitted by individual physicians, specialty societies, or manufacturers based on the AMA Criteria.
Code Applications Submitted through AUA
Code Applications Submitted through ACOG
Step 2: Submission to the CPT® Advisory Committee:
The CPT® manual is updated annually through an editorial review process overseen by the CPT® Editorial Panel. The CPT® Editorial Panel is responsible for maintaining the CPT code set. The Panel is authorized by the AMA Board of Trustees to revise, update, or modify CPT codes, descriptors, rules and guidelines. The Panel is composed of 21 members.
The CPT® Editorial Panel meets three times a year to review requests received from specialty societies, manufacturers and individuals. The Panel is supported in its deliberations by a larger body of CPT advisors, known as the CPT Advisory Committee. Supporting the CPT Editorial Panel in its work is a larger body of CPT advisors, the CPT Advisory Committee. The members of this committee are primarily physicians nominated by the national medical specialty societies represented in the AMA House of Delegates. Currently, the advisory committee is limited to national medical specialty societies seated in the AMA House of Delegates and to the AMA Health Care Professionals Advisory Committee (HCPAC), organizations representing limited-license practitioners and other allied health professionals. As a subspecialty society, AUGS does not have a seat in the HOD so participation is through either ACOG or AUA.
Once a request is approved through either AUGS, AUA or ACOG, staff or industry then submits a Code Change Proposal (CCP) to the AMA where it is posted for comment and review by the CPT ® Advisory Committee. The request is then slated for the agenda of the next AMA CPT® Editorial Panel meeting, where the CCP is approved or rejected.
Step 3: Submission to the RUC / RUC Survey
The Relative Value Scale Update Committee (RUC) is a joint AMA/Specialty Society decision-making body which reviews all survey recommendations of physician work values, practice expense, and Professional Liability Insurance. Through a rigorous review and voting process, the RUC determines a RVU for a procedure based on comparisons of other valued CPT codes and submits their recommendations to the Centers for Medicare and Medicaid Services (CMS) for reimbursement consideration. The volunteer members of the RUC are supported by staff and advisors from over 100 national medical specialty societies and health care professional organizations, representing the entire medical profession. (Source: AUA)
Once a CCP is accepted by the CPT® Editorial Panel, the next step in the CPT® process is to determine the reimbursement for the code, through a survey of physician work and determination of direct practice expense. The survey results are submitted to the RUC for negotiation for a mutually acceptable value to be submitted to CMS for final approval and publication in the Federal Register Final Rule. The approved CPT® code and their associated RVUs are then published in current coding manuals for use by physicians and their coding staff. (Source: AUA)
Learn more about the RUC Survey instrument with this overview from AMA.
