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Decoding the CPT RUC

What You Need to Know

Current Procedural Terminology (CPT) codes are required to report medical services and procedures and are part of the process in determining how physicians get paid. Unfortunately, there is a tremendous knowledge deficit among cardiovascular specialists about the CPT coding process, according to Diane Wallis, M.D., F.A.C.C., former chair of the ACC’s Coding and Nomenclature Committee.

First developed and published by the American Medical Association (AMA) in 1966, CPT is the preferred system for universally describing health care services and procedures, measuring performance and tracking new and emerging technologies. Medicare pays physicians according to a schedule that multiplies relative values for work and practice expenses—the Resource Based Relative Value Scale (RBRVS)—by a monetary conversion factor. Payments are then made on a per-visit or per-procedure basis as defined by the CPT codes. Most private payers take their cue from Medicare, but apply their own conversion factors. “The bottom line is that you can’t work unless you get paid. You can’t get paid without the codes. And you can’t use a code without an understanding of the process,” Wallis says.

Values are assigned to new CPT codes and re-evaluated for existing codes by the 27-member Relative Value Update Committee (RUC), which was formed in 1990 to make recommendations about the value of physician services to the Centers for Medicare and Medicaid Services (CMS). The American College of Cardiology has one of the seats on the committee. In addition, each cardiology subspecialty organization has a seat on the ACC Cardiovascular Relative Value Update Task Force (CVRUC), which determines how the ACC approaches RUC issues. Over the  last 20 years, the RUC has been responsible for valuing all new procedures and determining what physicians get paid. It takes many years for a service to move from clinical trials to approval for use to payment. The CPT and RUC processes take the developing treatments in medicine and eventually translate it into a language that allows insurers to pay for the service.

For questions on specific coding issues contact Debra Mariani at dmariani @acc.org .

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