Industry CPT Coding Assistance

AGA, ACG,ASGE Industry Coding and Reimbursement Declaration

The American Gastroenterological Association (AGA), the American College of Gastroenterology (ACG) and the American Society for Gastrointestinal Endoscopy (ASGE) have an active role in establishing and/or revising CPT® codes for new/existing procedures relevant to the practice of gastroenterology. The three societies coordinate this as a cooperative effort.  In recent years, the societies have introduced over 60 codes with matriculation through the CPT Editorial Panel, RBRVS Update Committee (RUC) and Practice Expense Subcommittee process, with assignment of reimbursement values by the Centers for Medicare and Medicaid Services (CMS). Through our direct interactions with CMS, C-codes and G-codes (CMS-issued procedure codes) have been established for new technologies that require more immediate coding for Medicare beneficiaries than possible with the traditional CPT/RUC process. The societies also provide comment to CMS regarding APC (hospital outpatient payment classification) rates and other reimbursement issues.

The ability to secure new codes has evolved through early communication with industry and provision of frequent guidance on issues pertinent to reimbursement. Often, these aspects are not inherent in the processes involved in FDA approval. The data necessary for optimizing reimbursement for practitioners should be considered when developing efficacy and safety studies to support widespread clinical use of new technology. These components of the process are aspects for which the gastroenterology societies are able to provide expertise.

To facilitate communication with industry, we have outlined the requisite information our organizations need to assist in the reimbursement process. We recognize that the phase of development of technology will vary and not accommodate the ability to provide all of this information initially. For these projects, we are able to provide guidance as the development matures. However, all should recognize that ultimately this information is needed when attempting to procure a category I CPT® code and the reimbursement associated with its use. The societies are prepared to assist companies to proceed along these lines at any step of their development. To prepare our representatives with the necessary information to support new procedures, we solicit input from individuals who are not directly involved in the development process but who have expertise in the area under consideration.

Although this critical review of the new technology may appear onerous, the CPT and RUC process will engage in this debate and our organizations recognize this preparation facilitates the best proposal. The following reflect our guidelines for assisting with this process.

View the AMA calendar of CPT and RUC meetings and deadlines. 

Requested Information from Industry to Facilitate Procurement of CPT® Code(s)

  1. A brief (five pages or less) executive summary of literature supporting the clinical utility of the device/procedure. Copies and reprints of articles and abstracts should accompany the submission. For less mature technologies, a descriptive narrative explaining the technology and preliminary investigation is adequate.
  2. A statement regarding which authors in quoted literature have financial ties (stock ownership, consulting fees, research support, advisory board, honorariums, venture capital / hedge fund) with the company. The presence of a financial relationship does not preclude utilization of the data that the investigator is responsible for.
  3. A review of safety data regarding the device/procedure.
  4. A CPT application should be completed by the requestor as completely as possible including peer-reviewed, published literature in support of the application.
  5. The requestor should provide data regarding physician work for the procedure (pre-, intra- and post-time) and practice expense for both the facility and non-facility settings.
  6. The requestor must provide the listed catalogue cost for any devices and supplies involved in performing the procedure.
  7. The requestor must provide the names of three physicians the company feels can comfortably analyze the procedure/device and who have no financial ties or involvement with research, venture capital or hedge fund advisory relationship with the company.
  8. Industry may forward a request to make presentations to representatives of ACG, AGA, and ASGE. Depending on the nature of the request, a teleconference or meeting with the representatives, at the requestor’s expense, may be scheduled. You may contact any one of the society liaisons below to initiate discussions.

For technology/devices that are in the early stages of development, items 4 and 6 may not be applicable.

Contact Society Liaisons To Initiate Discussions

  • Adam Borden, MHA, senior manager of new technology and reimbursement, American Gastroenterological Association (AGA),  301-941-2629, aborden@gastro.org.
  • Brad Conway, vice president, public policy, American College of Gastroenterology (ACG), 301-263-9000, bconway@acg.gi.org
  • Samuel Reynolds, MS, MBA, Assistant Director, Business and Practice Development, American Society for Gastrointestinal Endoscopy (ASGE), (630) 570-5643, sreynolds@asge.org.

CPT® is a registered trademark of the American Medical Association (AMA).