CPT and RUC committees, explained

A member recently emailed us concerned about the policy, which many consider pervasive, that third party payers follow to delay, or not pay, legitimate claims. He suggested that either the AMA CPT or RUC Committees should take some action to correct these policies.

Although the concern was appropriate, the suggested pathway for dealing with the issue is not correct. Both the Current Procedural Terminology (CPT) Editorial Panel and the Relative Value Scale Update Committee (RUC) are committees of the AMA.

The CPT Editorial Panel reviews, revises, maintains and approves new CPT codes. However, they do not set payments, nor regulate the payment of the codes by third party payers. 

The RUC is a multispecialty committee dedicated to describing the resources required to provide physician services. The Centers for Medicare & Medicaid Services (CMS) considers this information in developing Relative Value Units (RVUs). A subcommittee of the RUC reviews all input for costs into a given code. The RUC then reviews and either approves or modifies the final recommendation. This recommendation then goes to CMS for their final decision on RVUs. 

Neither the CPT nor the RUC have any control over how the final CPT codes are applied or paid by managed care. They are not regulatory bodies. They do not review nor have any input on the use of the codes by managed care.

Allergists are represented on both the CPT and RUC committees. James Sublett, MD, FACAAI serves as the CPT advisor. David Brown, MD, FACAAI, Gary Gross, MD, FACAAI and Dr. Sublett serve as advisors to the RUC. The advisors serve to explain the need for a new CPT code anddiscuss physician work involved, supply costs, procedure, etc.  Alnoor Malik, MD, FACAAI is the first allergist to sit on the RUC decision making committee.

Next week we will discuss one of the most common concerns we get questions about from membership; the denial of procedural codes when billed with an Evaluation and Management (E&M) office visit.