How is a New CPT Code “Created”?
How is a New CPT Code “Created”?
Date: March 24, 2025
Author: Bryan R. Hecht, MD, Member, ASRM Coding Committee
Have you ever performed a procedure but couldn’t find a corresponding procedure code for billing? Continuing innovation in the delivery of medical care drives the ongoing need for newly created Current Procedural Terminology (CPT) codes. Because billing and reimbursements are based on CPT codes, physicians understandably want to see newly created codes keep pace with rapidly evolving medical care. So, what is the process for creating a new CPT code? How long does the process take? And, just as important, how is a new code “valued” for reimbursement?
The creation and valuation of CPT codes is done so that CMS (Centers for Medicare and Medicaid Services) has a rationale for Medicaid/Medicare payments. Third party payers are not legally required to follow this system of valuation, but nearly all do.
Creating a new CPT code starts with the American Medical Association (AMA)’s CPT Editorial Panel, which originated over 50 years ago. The Panel, consisting of 17 members, representing physicians across multiple disciplines, the insurance industry, The American Hospital Association and CMS, is responsible for ensuring that CPT codes remain updated and accurately reflect contemporary clinical practice. The Panel meets three times per year, and these meetings are open to the public. The CPT Editorial Panel is also supported by another group of CPT advisors, the “CPT Advisory Committee”, which includes physicians nominated by various medical specialty societies. The Advisory Committee votes on whether to support each application for a new CPT code and that recommendation is forwarded to the Editorial Panel as part of their review. “Lobbying” any members of the Editorial Panel or the Advisory Committee for or against a code change is expressly prohibited.
A new CPT code may be proposed by any physician, professional society, medical device manufacturer, hospital or other stakeholder when they recognize that the absence of a CPT code impacts the documentation and reimbursement of a new medical procedure, technology, treatment or service. Specialty societies play an especially important role in this process by identifying gaps in the existing CPT codes and systematically gathering feedback from their members. Specialty societies often include a coding and nomenclature committee to help develop and review proposed changes to the CPT code set.
The process begins when a “CPT Code Change Application” is submitted to the Panel. The application for a new code requires a complete description of the proposed procedure or service, including the skill level and time involved. A clinical vignette or operative report may be included, as well as peer reviewed articles supporting the safety and effectiveness of the procedure and estimates of the current and projected future frequency that the procedure is or will be performed.
The criteria that the Editorial Panel considers includes whether there is sufficient research to justify the new code, the frequency of the new procedure, and whether the new procedure is sufficiently unique and different from current practices to justify a new code. The results are included in the annual release of the “Medicare Physician Fee Schedule (PFS) Final Rule”, which outlines all new changes and updates to Medicare payments and policies.
Once a new code is approved, or an older code is revised, it is then referred to CMS, which assigns a reimbursement value to the code, determining payment for that service under Medicare. Physicians have input into this process through the Relative Value Scale Update Committee (RUC), which consists of 31 physicians and other health care professionals representing a variety of specialties and sectors of Medicine. The RUC, which also meets 3 times per year, considers all relative value codes that have been changed or added by the CPT Editorial Panel. The RUC evaluates the physician time, the intensity and complexity of the service, the level of professional skill needed, and any related practice expenses or resources.
The RUC value recommendations are based on the results of carefully evaluated surveys that are completed and compiled by the specialty societies that represent the primary providers of the service or procedure. These surveys are distributed to a random sample of practicing clinicians who perform the service or procedure, and input from those clinicians plays a critical role in the valuation of the new CPT code. The surveys are long and very detailed. If you should happen to receive a survey, please remember how important they are, and ensure that yours is completed accurately.
Despite the fact that medical costs continue to rise, Congress has placed a statutory budget neutrality requirement for payments to physicians. Therefore, when CMS approves a new CPT code, and RUC assigns a value to the new code, this too must be budget neutral. There were 270 new codes added to CPT in 2025, yet the amount of funding that Congress allots for that year to Medicaid will not increase. The revenue to pay for a new CPT code comes from a slight reduction in the RVUs from other members within the same family of CPT codes. If the new code is expected to have high utilization it may trigger a resurveying of all of the CPT codes within that family.
The process for creating and valuing a new or updated CPT code is very systematic and carefully structured, which helps explain why the process is also very lengthy. The entire new CPT code application process can take up to 24 months to complete.
The prior discussion refers to Category I CPT codes. Another subset of CPT codes, the Category III CPT codes, are temporary tracking codes for new and emerging technologies to allow data collection and assessment of new services and procedures. They are used to document the usage of the new technology in order to then establish a permanent (Category I) CPT code. Category III codes can be recognized by their numeric alpha format, e.g., 0307T. There are no fees assigned to these codes, so payment is at the discretion of the insurance carrier or Medicare. The specific requirements for submitting a request for a Category III code are much more limited than for a Category I code request, but includes supportive peer-reviewed literature, an approved US clinical trial and endorsements by a specialty society. New Category III CPT remain active for up to 5 years. Category III codes are released twice per year.
For ASRM members interested in the development of new CPT codes, please reach out to the ASRM Coding Committee. We work with ACOG to propose procedures that are in need of CPT codes.
This blog post was developed under the direction of the Coding Committee of the American Society for Reproductive Medicine as a service to its members and other practicing clinicians.
The following members of the ASRM Practice Committee participated in the development of this document: Bryan Hecht, MD; Mindy Christianson, MD; and John Queenan, Jr, MD.
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