EXECUTIVE SUMMARY
The American Medical Association (AMA) has successfully operated and maintained the Physicians' Current Procedural Terminology (CPT) system, a private sector initiative, for over 30 years. Prior to the development and copyright of the CPT system, it was estimated that over 250 different procedural coding systems existed. The multiplicity of procedural coding systems was inefficient, chaotic and clearly detrimental to those interested in obtaining reliable data on medical services provided to patients. Today, market acceptance for CPT is high, with estimates that over 95 percent of all services provided by physicians are reported using the CPT coding system.
The AMA has demonstrated its commitment to providing for the total quality improvement of the CPT system and rendered the necessary leadership and capital investment to oversee its ongoing evolution in a democratic fashion. Specifically, the AMA has developed a tested and comprehensive structure focused on the continuous improvement of CPT by the CPT Editorial Panel, the entity responsible for its maintenance. This Editorial Panel is broadly representative, comprised of constituents from the Blue Cross and Blue Shield Association (BC/BS), the Health Insurance Association of America (HIAA), the Health Care Financing Administration (HCFA), and the American Hospital Association (AHA), as well as the AMA.
The composition of the CPT Editorial Panel was recently expanded to include non-MD health professionals and physician representatives with specialized knowledge of the coding requirements of the managed care community. It is worth noting that the Editorial Panel is supported by CPT Advisory Committees that represent a large number of medical specialty societies and professional organizations such as nursing, podiatry, psychology, physical therapy, chiropractic and other health care professionals. In short, the CPT system is supported by a voluntary network of nearly 1000 knowledgeable health care professionals in a public fashion.
In addition, under the AMA's stewardship, and with the assistance of a broad array of medical and other health professionals, CPT has met with both private and public sector critical review and approval and served as the natural means to provide a low cost system of distribution. For example, in 1983, CPT was chosen by HCFA as the procedural coding system for the Medicare and Medicaid programs. The AMA has maintained the CPT system under its agreement with the federal government and has provided annual updates and improvements to HCFA and its agents at no cost.
The CPT system has demonstrated its responsiveness to the coding needs of the health care system. One of the most important events in the ongoing evolution of CPT was the decision by Congress to restructure the process by which physicians are paid for their services under the Medicare system. In immediate and direct response to the transition to the Medicare Resource-Based Relative Value (RBRVS)-based physician payment system, the CPT Editorial Panel revised the codes for visits and consultations.
CPT's fundamental purpose is to provide an organized listing of descriptive terms and identifying codes for the reporting of physician services.
It is used to describe medical, surgical and diagnostic services and is also widely relied on for use an administrative management and the development of guidelines for medical care review. It is also applicable to medical education and clinical research by offering a useful basis for local, regional and national utilization comparisons. CPT has become the single uniform coding system that reporting of services provided by physicians and other health care professionals.
In a recent survey of randomly selected physicians involved in direct patient care, 95 percent of physicians stated that they believe it is important that the coding system used by physicians for patients should be developed by the medical profession (Gordon S. Black, Inc., January/February 1997). Along with a number of similar findings, the results of the survey show the tremendous importance that physicians place on being able to describe the services they provide in terms that they believe are clinically meaningful. The results also support and reinforce the AMA's long-held view that the medical profession must maintain its code sets and that the AMA, given its structure and resources, is the body best suited to handle that responsibility.
The AMA strongly recommends that the CPT system be recognized as one of the initial standards for administration transactions as required by the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191). We believe that the rationale and criteria used by the Department of Health and Human Services in choosing the CPT system in the past continues to have merit to date. CPT is the best system for the job because it can be implemented nationally without disruption to the existing data processing activities.
The costs of implementing any system other than CPT would be enormous. A recent update to a study conducted by Coopers & Lybrand stated the estimated costs of developing and implementing a uniform procedural coding system to be nearly $1 billion (Argus/Arista March 1997). The CPT has a proven track record and has successfully ensured that the code sets are available to all interested parties in an efficient, low cost and fair manner.
1. What medical/clinical codes and classifications do you use in administrative transactions now? What do you perceive as the main strengths and weaknesses of current methods for coding and classification of encounter and/or enrollment data?
The two major classification systems used by physicians in administrative transactions are CPT (and the remainder of HCFA's Common Procedure Coding System) to describe medical procedures and ICD- 9 for diagnosis coding. The CPT system is today recognized as the single uniform coding system for the reporting of physician services. Today it is estimated that over 95 percent of all services provided by physicians are reported using the CPT coding system. The overwhelming choice of Federal, state, and private health programs, CPT is used for determining proper payment for physician and non-physician services, for administrative management and the development of guidelines for medical care review.
2. What medical/clinical codes and classifications do you recommend as initial standards for administrative transactions, given the time frames in the HIPAA? What specific suggestions would you like to see implemented regarding coding and classification?
The AMA unequivocally recommends that the CPT system be recognized as the standard for physician services for administrative transactions. We believe that the criteria used by the Secretary in initially choosing CPT as the basis for a Medicare coding system still have merit for the longer term. It is the most desirable system because it: can be implemented nationally with a minimum of disruption to existing data processing activities; can be implemented without fear of increasing costs to the health care system; is acceptable to the medical profession; and there is a professional commitment to maintain it.
3. Prior to the Passage of HIPAA, the National Center for Health Statistics initiated development of a clinical modification of ICD-10 (ICD-10-CM), and the Health Care Financing Administration undertook development of a new procedure coding system for inpatient procedures (called ICD-10-PCS), with a plan to implement them simultaneously in the year 2000. On the pre-HIPAA schedule, they will be released to the field for evaluation and testing by 1998. If some version of ICD is to be used for administrative transactions, do you think it should be ICD-9-CM or ICD-10-CM and ICD-10-PCS, assuming that field evaluations are generally positive?
The AMA supports the continued usage of ICD-9-CM. To date, there has been insufficient involvement of the medical profession in issues pertaining to ICD-10, so that it is not now possible to draw solid clinical conclusions about its practical superiority to ICD-9-CM. Discussions of the need for the development of an ICD-10-CM are also premature. There is a need for more meaningful educational programs about the philosophy and structure behind ICD-10 and, pending the outcomes of those reviews, we see no reason why that could not be done on a timetable to meet the implementation dates specified by the legislation. The network of physician coding experts assembled through the CPT Advisory Committee would be an excellent way to pursue that review in a timely and serious manner and the AMA would be more than willing to help facilitate that. We remain skeptical of the feasibility of ICD-10-PCS due to the introduction of an overwhelming number of new codes (perhaps up to 150,000) being introduced into the health care system.
4. Recognizing that the goal of P.L. 104-191 is administrative simplification, how, from your perspective, would you deal with the current coding environment to improve simplification, reduce administrative burden, but also obtain medically meaningful information?
Within the framework of CPT there are two administrative efficiencies that could be achieved within the context of HIPAA. One, is the usage of modifiers. For CPT to work correctly, and for all available efficiencies to be manifest, it is essential that all health insurance companies accept modifiers as part of their claims processing systems. A second is uniform adherence to the CPT rules. We believe that all insurance companies should be required to follow the notes, guidelines and instructions that accompany the codes and descriptors. They should also be required to use the most recent issue of CPT. Without such adherence physicians are faced with multiple sets of coding rules, that often distort the intended meaning of the codes and, in effect, may require physicians to submit codes that are less than fully descriptive of the services actually provided.
5. How should the ongoing maintenance of medical/clinical code sets and the responsibility, intellectual input and funding for maintenance be addressed for the classification systems included in the standards? What are the arguments for having these systems in the public domain versus in the private sector, with or without copyright?
The AMA has willingly expended significant resources in the past to develop and maintain the CPT system. The AMA is prepared to continue the process of refining, improving, and maintaining the CPT system to make it responsive to the needs of the health care community. We feel strongly that it is in the public's interest for the Secretary to advocate the "best coding systems to do the job" regardless of whether such systems are public-domain or not. There is nothing inherent in the proprietary status of a code set that makes it more or less useful for the purposes specified by the legislation.
6. What would be the resource implications of changing from the coding and classification systems that you currently are using in administrative transactions to other systems? How do you weigh the costs and benefits of making such changes?
The AMA believes that the costs of creating a new coding system would be extraordinarily prohibitive and disruptive. Independent studies done by Coopers and Lybrand in 1989 suggested that the costs of a newly developed uniform coding system could approximate $700 million. Recent estimates from the study's authors conservatively indicate those amounts, in 1997 dollars, as between $866 million and $993 million. We believe that with appropriate modification, CPT can easily and readily (i.e. within the timeframes specified by the HIPAA legislation) become the single, uniform coding system that so many have advocated.
7. A coding and Classification Implementation Team has been established within the Department of Health and Human Services to address the requirements of P.L. 104-191, the Teams charge is enclosed. Does your organization have any concerns about the process being undertaken by the Department to carry out the requirements of the law in regard to coding and classification issues? If so, what are those concerns and what suggestions do you have for improvements?
The AMA is well aware of the Classification Implementation Team's charter. We have absolute confidence that the Secretary will recognize the critical importance of not disrupting patient care by imposing an untried and untested coding and classification system. CPT works well today but it can and will be improved. The CPT system can meet the specifications of the HIPAA legislation. Subcommittee recommendations and/or suggestions for further refinements in CPT would be welcomed.