Coding and Payment

The introduction to the American Medical Association's Current Procedural Terminology states, in part:

Current Procedural Terminology, (CPT), Fourth Edition, is a set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other health care providers.

Inclusion of a descriptor and its associated specific five-digit code number in the CPT codebook is based on whether the procedure is consistent with contemporary medical practice and is performed by many practitioners in clinical practice in multiple locations.

The American Academy of Family Physicians supports this position. The Academy agrees that CPT describes the services that physicians provide and that inclusion of a service in CPT reflects contemporary medical practice.

The Academy is not alone in its support for CPT and the coding principles it contains. The U.S. Department of Health and Human Services has adopted CPT, in combination with the Healthcare Common Procedure Coding System, as the standard medical data code set for physician services under the Health Insurance Portability and Accountability Act. Thus, CPT has both medical and regulatory recognition.

Given this recognition, the Academy believes that it is important for both physicians and health plans to abide by the principles of CPT. For physicians, this means selecting the code that accurately identifies the service performed and documented. It also means that when a single code accurately describes multiple services provided by the physician, the physician should report that code rather than codes for each of the individual services provided.

For health plans, abiding by the principles of CPT means that payment for covered services should be based on the codes documented and billed by the physician. It also means that health plans should only bundle codes for payment consistent with CPT guidelines. Automatic, unilateral downcoding of physician reported CPT codes and bundling of codes contrary to CPT is not acceptable. It is also not acceptable for health plans to threaten to or actually restrict, terminate, or exclude a family physician from plan participation based on his or her coding pattern if the family physician provides medically necessary services and conscientiously abides by the principles and rules of CPT coding. The Academy expects health plans to abide by CPT rules and is concerned about any variance from those rules.
(2002) (2010 COD)