Procedural Terminologies and Codes
Current Procedural Terminology Coded Services
Current procedural terminology coded services (CPT) include more than 8,000 services listed in the Physicians' Current Procedural Terminology manual published annually by the American Medical Association (AMA), Developed by the AMA in 1966.
The purpose of the CPT system is to provide a uniform language that describes medical, surgical, and diagnostic services and thereby serves as a method for payment by public (Medicare and Medicaid) and private (commercial insurers) payers.
It is used by
policy makers in their deliberations on reforming the payment system.
Steps For PPRC
In 1986 Congress created the Physician Payment Review Commission (PPRC) to advise it on reforms of the methods used to pay physicians under the Medicare program (Part B).
Nursing groups such as the American Nurses Association lobbied PPRC to consider the contributions of nurses as they engaged in the process of revising the payment system.
In its report to Congress, the PPRC stated that non physician providers should be paid at a percentage of physician payment levels. reflecting differences in physicians' and non- physicians' resource costs: work as well as practice and malpractice expense.
Response of ANA And Nursing Role
The American Nurses Association (ANA)
disagreed, stating that nurses should be paid the same for the same service
(Mittelstadt, 1991). The first nurse to serve on the Commission, Carol
Lockhart, PhD, RN, FAAN, expressed concern about the lack of nursing data
available to the PPRC. She stated:
Nursing's role in the delivery of
Medicare Part B services is undocumented. We have little or no data showing how
much of a particular service, now billed by a physician, is done by a nurse, or
how many services are delivered by the nurse and hilled under the physician's
name. (Griffith & Fonteyn, 1989, p. 1051)
In an attempt to identify whether CPT codes might explain nursing work and there- fore provide the needed data, studies were conducted to look at how many billable CPT activities were performed by nurses (Griffith, Thomas, & Griffith, 1991; Griffith & Robinson, 1993; Robinson & Griffith, 1997).
The American Journal of Nursing (AJN) (Griffith & Fonteyn, 1989) published a questionnaire on the performance of CPT-coded procedures by registered nurses; 4,869 RNs returned the questionnaire and 150 made telephone calls or wrote letters.
The average number of coded services performed by the respondents was 27, with a range of 0 to 60 (Griffith et al., 1991). Given the large number of currently published codes in the manual, this number appears to be small; however, at the time of the survey, only 107 codes comprised 56.9% of all Medicare procedures (Health Care Financing Administration and Bureau of Data Management and Strategy, 1990).
Survey results revealed that associate and baccalaureate degree nurses performed significantly more coded services than nurses with diplomas and master’s degrees. The more experienced nurses (practicing more than 10 years) reported performing significantly fewer coded services and, as expected, nurses working in hospital settings performed more services.
This exploratory study suggested
that nurses often perform CPT-coded services with little or no supervision by
physicians.
After realizing that the generalist A/N study was clearly supported by nurses, nine nurse specialist groups were surveyed and it was determined that 493 of over 7,000 CPT codes were performed by school nurses, intrastromal nurses, family nurse practitioners, critical care nurses, oncology nurses, rehabilitation nurses, orthopedic nurses, nephrology nurses, and midwives (Griffith & Roiinson, 1993; Robinson & Griffith, 1997).
The number of CPT codes performed by specialty nurses ranged from 233 for family nurse practitioners to 58 for school nurses. The mean number of coded services per- formed by individual respondents ranged from 79 for family nurse practitioners to 18 for school nurses; individual respondents per- formed 0 to 162 codes.
Supervision by physicians for these groups of nurses was infrequent. Charges to Medicare in 1988 for the coded services included in the survey were $22,793,427.34 (aggregate allowable charges).
A criticism of the CPT codes is their limitation to describe only physician services and not the full range of health services provided by the entire team.
In a study comparing the frequency with which nursing activity terms could be categorized using Nursing Interventions Classification (NIC) and Current Procedural Terminology (CPT) codes, findings revealed evidence that NIC is superior to CPT for categorizing these activities in a study population of 201 AIDS patients hospitalized for pneumocystis carinii pneumonia.
Nursing activity terms were categorized into 80 NIC interventions across 22 classes and into 15 CPT codes. All terms in the data set were classifiable using the NIC system and 60% of the terms were classified into 14 NIC intervention categories while only 6% of the terms were classifiable by CPT codes.
These findings supported the importance of nursing- specific classifications for categorization of health care interventions in an effort to demonstrate nursing's contribution to quality and cost outcomes (Henry, Holzemer, Randell, Hsieh, & Miller, 1997).
However, another way to address the issue is to introduce nursing
services into CPT it they are not otherwise described in another CPT code
(Sullivan- Marx & Mullinix, 1999).
Deficiencies of CPT
Recognizing that the CPT system does have deficiencies, the AMA, in 1998, began the task of developing the next generation, the CPT-5. The CPT-5 Project includes six workgroups and an Executive Project Advisory Group (PAG).
One of the workgroups, "Non Physician Practitioners," is reviewing and evaluating weaknesses of the current system for coding the provisions of health services by non physician health care professionals (http://www.ama-assn.org/ama/pub/ category/3883.html).
Efforts are being made to gather information from other provider organizations to determine where and how the CPT system lacks adequate codes for the appropriate description of services of different providers. It is anticipated that the CPT- 5 Project will be completed in the near future.
ANA,
active in dialogues with AMA on inclusion of nursing work in CPT-5, has
representatives serving on AMA work groups of the project (Robinson, Griffith,
& Sullivan- Marx, 2001).
As we progress further through the 21st century, the public consumers of care that nurses deliver will become even more interested in cost, accessibility, satisfaction, and quality. Because nurses have the abilities to deliver in all of these areas, they should be directly reimbursed for their services.
If nurses want to proceed in this direction, then their challenge must be to accurately document their contribution of nursing practice to patient and program productivity and effectiveness through workload analysis, thereby providing meaningful data to consumers, policy makers, and payers (Robinson et al., 2001).
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