3P Update: Academy Efforts Regarding New Technology
James C. Denneny III, MD Coordinator for Socioeconomic Affairs Co-Chair of Physician Payment Policy Workgroup (3P) Background The AAO-HNS CPT team is responsible for ensuring that there is an accurate descriptor for physician work provided to our patients. This includes revising code descriptions for existing CPT codes as well as submitting applications for new CPT codes where the work is not described in the existing code’s structure. There are prescribed criteria for recommending editorial changes, as well as submitting new code applications. Editorial changes typically do not result in any change to the assigned value of a CPT code, however, a new code will require valuation through the AMA Relative Update Committee (RUC) process, and is subject to final approval by CMS through annual rulemaking. There are two types of CPT Codes, Category I and Category III. Category I codes are “Standard codes,” but do not guarantee insurance reimbursement, and typically have a higher threshold of utilization, literature support, and are a standard of care. Category III codes are issued for new technologies that have less literature support, may be used for tracking, and are not valued by RUC, but may be paid by insurers. Access our website here for more information on the CPT Editorial Process: http://www.entnet.org/Practice/Applying-for-CPT-codes-and-Obtaining-RVU.cfm. The AAO-HNS has an experienced team on both the CPT and RUC side of the process. The 3P workgroup oversees and coordinates the operations of both the CPT and RUC teams with the assistance of the appropriate AAO-HNS committees. The combined experience of the members of these teams is more than 50 years. There are two recent examples of how the New Technology Pathway process works which have created interest among our members. 1. New CPT Code for Endoscopic Zenker’s Diverticulotomy Recently, a new CPT code for endoscopic Zenker’s diverticulotomy was created and will be undergoing RUC survey for the January 2014 RUC meeting. This occurred based on a change in treatment patterns over the last several years for Zenker’s diverticulum. Given that there was not a CPT code that accurately described the work done when an endoscopic approach was utilized; a proposal to create a new code was submitted to the CPT Editorial Panel to accurately describe that work and is likely to appear in the 2015 CPT book. 2. New Technology Pathway Application for Propel® Drug Eluting Stents Additionally, an application was received from IntersectENT through the Academy’s New Technology Pathway process (see: http://www.entnet.org/Practice/Valuing-CPT-Codes.cfm), which requested the creation of a Category I CPT code for the insertion of a drug eluting stent used in the treatment of sinus disease. We commend Intersect ENT for utilizing our prescribed process to present information relating to the use of their device. The 3P group, in conjunction with consultation from the Rhinology and Paranasal Sinus Committee (RPS) and CPT/RVU Committee, reviewed the information submitted by the company over a number of months. We reviewed the literature, had conversations with the company, visited the company’s exhibit at our recent meeting in Vancouver, received instruction in the insertion of the product, and had consultations with a number of rhinologists including those on RPS Committee 3P also met by email, phone and in person multiple times to discuss this issue. Members of the workgroup have been involved in the evaluation of sinus codes since the introduction of endoscopic sinus surgery. This includes the latest two valuations at the RUC. Based on this experience, 3P felt that the work described for the placement of the drug eluting stent in the operating room immediately following sinus surgery is already described and valued in the existing endoscopic CPT codes. In fact, there is a provision in each of these codes for placement of packing, spacers, and medications in the sinus cavities following endoscopic surgery. Surgeons across the country use a variety of materials following endoscopic surgery at the close of the procedure, and some do not use anything. The current work descriptor valued by the RUC includes the placement of these materials, when performed in the intraoperative setting; therefore, we do not feel there is sufficient justification for the creation of a new CPT code in the hospital outpatient setting. This does not prevent the stent, which is FDA approved, from being used. A similar scenario might exist if there were a new packing developed for ear surgery. The work to place the packing is already accounted for in the existing code valuation and positioning this newly developed packing would not be separately reported or reimbursed. 3P, however, felt that there would be a place for a new Category III CPT code relating to the in-office use of this drug eluting stent once evidence of efficacy in the office is demonstrated in the literature. The key will be to define the correct code structure in the context of existing ones and the development of literature to demonstrate adequate support for a Category I code. Thus, 3P recommended that Intersect ENT proceed with a request for a Category III CPT Code. This recommendation was also approved by the AAO-HNS Executive Committee. We also continue to collaborate with ARS leadership, as we have done on other rhinology issues in the past, and we are in communication with them about our decision. Our CPT and RUC teams have developed a very strong reputation for objectivity and accurate valuation of our codes over many years. Our reputation for integrity dealing with the CPT/RUC processes and health policy, in general, is paramount to us as the society representing Otolaryngology in this arena. We will continue to objectively participate in these activities on behalf of our members. For any comments or questions, please contact Dr. Denneny via the Health Policy team at HealthPolicy@entnet.org. AMA Criteria for all CPT codes The proposed descriptor is unique, well-defined, and describes a procedure or service which is clearly identified and distinguished from existing procedures and services already in CPT. The descriptor structure, guidelines and instructions are consistent with current Editorial Panel standards for maintenance of the code set. The proposed descriptor for the procedure or service is neither a fragmentation of an existing procedure or service nor currently reportable as a complete service by one or more existing codes (with the exclusion of unlisted codes). However, procedures and services frequently performed together may require new or revised codes. The structure and content of the proposed code descriptor accurately reflects the procedure or service as typically performed. If always or frequently performed with one or more other procedures or services, the descriptor structure and content will reflect the typical combination or complete procedure or service. The descriptor for the procedure or service is not proposed as a means to report extraordinary circumstances related to the performance of a procedure or service already described in the CPT code set. The procedure or service satisfies the category-specific criteria set forth below. AMA Criteria for Category I Code All devices and drugs necessary for performance of the procedure or service have received FDA clearance or approval when such is required for performance of the procedure or service. The procedure or service is performed by many physicians or other qualified health care professionals across the United States. The procedure or service is performed with frequency consistent with the intended clinical use (i.e., a service for a common condition should have high volume, whereas a service commonly performed for a rare condition may have low volume). The procedure or service is consistent with current medical practice. The clinical efficacy of the procedure or service is documented in literature that meets the requirements set forth in the CPT code change application. AMA Criteria for Category III Code The procedure or service is currently or recently performed in humans; AND At least one of the following additional criteria has been met: The application is supported by at least one CPT or HCPAC advisor representing practitioners who would use this procedure or service; OR The actual or potential clinical efficacy of the specific procedure or service is supported by peer reviewed literature which is available in English for examination by the Editorial Panel; OR There is; a) at least one Institutional Review Board approved a protocol of a study of the procedure or service being performed, b) a description of a current and ongoing United States trial outlining the efficacy of the procedure or service, or c) other evidence of evolving clinical utilization.
James C. Denneny III, MD
Coordinator for Socioeconomic Affairs
Co-Chair of Physician Payment Policy Workgroup (3P)
Background
The AAO-HNS CPT team is responsible for ensuring that there is an accurate descriptor for physician work provided to our patients. This includes revising code descriptions for existing CPT codes as well as submitting applications for new CPT codes where the work is not described in the existing code’s structure. There are prescribed criteria for recommending editorial changes, as well as submitting new code applications. Editorial changes typically do not result in any change to the assigned value of a CPT code, however, a new code will require valuation through the AMA Relative Update Committee (RUC) process, and is subject to final approval by CMS through annual rulemaking.
There are two types of CPT Codes, Category I and Category III. Category I codes are “Standard codes,” but do not guarantee insurance reimbursement, and typically have a higher threshold of utilization, literature support, and are a standard of care. Category III codes are issued for new technologies that have less literature support, may be used for tracking, and are not valued by RUC, but may be paid by insurers. Access our website here for more information on the CPT Editorial Process: http://www.entnet.org/Practice/Applying-for-CPT-codes-and-Obtaining-RVU.cfm.
The AAO-HNS has an experienced team on both the CPT and RUC side of the process. The 3P workgroup oversees and coordinates the operations of both the CPT and RUC teams with the assistance of the appropriate AAO-HNS committees. The combined experience of the members of these teams is more than 50 years.
There are two recent examples of how the New Technology Pathway process works which have created interest among our members.
1. New CPT Code for Endoscopic Zenker’s Diverticulotomy
Recently, a new CPT code for endoscopic Zenker’s diverticulotomy was created and will be undergoing RUC survey for the January 2014 RUC meeting. This occurred based on a change in treatment patterns over the last several years for Zenker’s diverticulum. Given that there was not a CPT code that accurately described the work done when an endoscopic approach was utilized; a proposal to create a new code was submitted to the CPT Editorial Panel to accurately describe that work and is likely to appear in the 2015 CPT book.
2. New Technology Pathway Application for Propel® Drug Eluting Stents
Additionally, an application was received from IntersectENT through the Academy’s New Technology Pathway process (see: http://www.entnet.org/Practice/Valuing-CPT-Codes.cfm), which requested the creation of a Category I CPT code for the insertion of a drug eluting stent used in the treatment of sinus disease. We commend Intersect ENT for utilizing our prescribed process to present information relating to the use of their device. The 3P group, in conjunction with consultation from the Rhinology and Paranasal Sinus Committee (RPS) and CPT/RVU Committee, reviewed the information submitted by the company over a number of months. We reviewed the literature, had conversations with the company, visited the company’s exhibit at our recent meeting in Vancouver, received instruction in the insertion of the product, and had consultations with a number of rhinologists including those on RPS Committee 3P also met by email, phone and in person multiple times to discuss this issue.
Members of the workgroup have been involved in the evaluation of sinus codes since the introduction of endoscopic sinus surgery. This includes the latest two valuations at the RUC. Based on this experience, 3P felt that the work described for the placement of the drug eluting stent in the operating room immediately following sinus surgery is already described and valued in the existing endoscopic CPT codes. In fact, there is a provision in each of these codes for placement of packing, spacers, and medications in the sinus cavities following endoscopic surgery. Surgeons across the country use a variety of materials following endoscopic surgery at the close of the procedure, and some do not use anything. The current work descriptor valued by the RUC includes the placement of these materials, when performed in the intraoperative setting; therefore, we do not feel there is sufficient justification for the creation of a new CPT code in the hospital outpatient setting. This does not prevent the stent, which is FDA approved, from being used. A similar scenario might exist if there were a new packing developed for ear surgery. The work to place the packing is already accounted for in the existing code valuation and positioning this newly developed packing would not be separately reported or reimbursed.
3P, however, felt that there would be a place for a new Category III CPT code relating to the in-office use of this drug eluting stent once evidence of efficacy in the office is demonstrated in the literature. The key will be to define the correct code structure in the context of existing ones and the development of literature to demonstrate adequate support for a Category I code. Thus, 3P recommended that Intersect ENT proceed with a request for a Category III CPT Code. This recommendation was also approved by the AAO-HNS Executive Committee. We also continue to collaborate with ARS leadership, as we have done on other rhinology issues in the past, and we are in communication with them about our decision.
Our CPT and RUC teams have developed a very strong reputation for objectivity and accurate valuation of our codes over many years. Our reputation for integrity dealing with the CPT/RUC processes and health policy, in general, is paramount to us as the society representing Otolaryngology in this arena. We will continue to objectively participate in these activities on behalf of our members. For any comments or questions, please contact Dr. Denneny via the Health Policy team at HealthPolicy@entnet.org.
AMA Criteria for all CPT codes
- The proposed descriptor is unique, well-defined, and describes a procedure or service which is clearly identified and distinguished from existing procedures and services already in CPT.
- The descriptor structure, guidelines and instructions are consistent with current Editorial Panel standards for maintenance of the code set.
- The proposed descriptor for the procedure or service is neither a fragmentation of an existing procedure or service nor currently reportable as a complete service by one or more existing codes (with the exclusion of unlisted codes). However, procedures and services frequently performed together may require new or revised codes.
- The structure and content of the proposed code descriptor accurately reflects the procedure or service as typically performed. If always or frequently performed with one or more other procedures or services, the descriptor structure and content will reflect the typical combination or complete procedure or service.
- The descriptor for the procedure or service is not proposed as a means to report extraordinary circumstances related to the performance of a procedure or service already described in the CPT code set.
- The procedure or service satisfies the category-specific criteria set forth below.
AMA Criteria for Category I Code
- All devices and drugs necessary for performance of the procedure or service have received FDA clearance or approval when such is required for performance of the procedure or service.
- The procedure or service is performed by many physicians or other qualified health care professionals across the United States.
- The procedure or service is performed with frequency consistent with the intended clinical use (i.e., a service for a common condition should have high volume, whereas a service commonly performed for a rare condition may have low volume).
- The procedure or service is consistent with current medical practice.
- The clinical efficacy of the procedure or service is documented in literature that meets the requirements set forth in the CPT code change application.
AMA Criteria for Category III Code
- The procedure or service is currently or recently performed in humans; AND
- At least one of the following additional criteria has been met:
- The application is supported by at least one CPT or HCPAC advisor representing practitioners who would use this procedure or service; OR
- The actual or potential clinical efficacy of the specific procedure or service is supported by peer reviewed literature which is available in English for examination by the Editorial Panel; OR
- There is; a) at least one Institutional Review Board approved a protocol of a study of the procedure or service being performed, b) a description of a current and ongoing United States trial outlining the efficacy of the procedure or service, or c) other evidence of evolving clinical utilization.