The American Academy of Family Physicians (AAFP) recognizes the U.S. Department of Health and Human Services has adopted Current Procedural Terminology (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. Given this recognition and for the sake of administrative simplicity, the AAFP believes it is important for both physicians and health plans to abide by the principles of CPT, especially in a fee-for-service payment system. For physicians, this means selecting the code that most accurately identifies the service performed and documented.
For health plans, abiding by the principles of CPT means 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 their coding pattern if the family physician provides medically necessary services and conscientiously abides by the principles and rules of CPT coding. The AAFP expects health plans to abide by CPT rules and opposes any variance from those rules in a fee-for-service payment system.
The AAFP also recognizes that CPT does not allow family physicians to report in a fee-for-service system the full breadth and depth of the care they provide their patients. The AAFP works with the American Medical Association, the Centers for Medicare & Medicaid Services, and other stakeholders to develop codes or other mechanisms that allow family physicians to report the breadth and depth of the care they provide their patients in a fee-for-service payment system.
Additionally, consistent with the “AAFP Guiding Principles for Value-Based Payment,” the AAFP works with the American Medical Association, the Centers for Medicare & Medicaid Services, and other stakeholders to develop alternative payment models that include prospective population-based payments that adequately fund the breadth and depth of services provided in primary care and are less reliant on fee-for-service and CPT. The AAFP supports a wide range of possible payment reforms to resolve the inadequacies of fee-for-service for primary care, including family medicine.
(2002) (October 2023 COD)