NPs are an integral part of transforming healthcare in the 21st century. NPs are cost-effective providers who support changes to solve the challenges of cost, quality, and access to healthcare.1 The expansion of NPs' scope of practice over the last decade has increased revenue potential with entrepreneurial opportunities.2 However, overall reimbursement for healthcare has decreased while the pool of consumers requiring care continues to grow.1 NPs are valued members of the healthcare team, and their numbers are growing each year. Over the past 20 years, there has been exponential growth in the number of NPs, with over 355,000 in the US as of 2022.3 The impact NPs have on care quality, safety, patient satisfaction, and access is substantial; however, the measurement to demonstrate NP value in these areas is lacking.4 There is a dearth of research data describing NP productivity measurement and how existing productivity models for physicians might be adapted to measure NP productivity.4 Therefore, it is imperative that NPs take an active role in ensuring that provided services are consistently documented and accurately captured on encounter claims to maximize reimbursement. To ensure correct billing and coding, NPs must become competent in use of the Current Procedural Terminology (CPT®) system and learn how their work is reimbursed based on relative value units (RVUs). CPT system The CPT system, developed by the American Medical Association (AMA), provides standard language and numerical coding as the process used to communicate services provided by NPs and other qualified healthcare professionals (QHPs) to the Centers for Medicare and Medicaid Services (CMS) as well as other third-party payers for reimbursement. CPT codes are used to describe tests, surgeries, evaluations, and any other medical procedures performed by healthcare providers.5 An understanding of the reimbursement system is key for survival in today's healthcare environment, as erroneous coding may result in a substantial loss of revenue or imposition of monetary penalties.6 NPs already contend with disproportionately lower reimbursement. For example, Medicare, Medicaid, and some third-party payers reimburse NP services at 85% of the physician rate for the same billable CPT code service.1 NPs and other advanced practice registered nurses are among the top providers performing many CPT code services reimbursed by Medicare, hence the importance of having a seat at the table to discuss and advise on changes to CPT.7 RVUs RVUs are a measurement of practice efficiency and patient complexity.5 An RVU has three components: provider's work, practice expense, and professional liability insurance expense.8,9 For example, an NP's work RVUs include clinical skills and time needed to treat a patient during an encounter.5 Practice expense RVUs consist of the practice's overhead, such as the expenses for building space, equipment, office supplies, and clinical staff time (such as the work of licensed practical nurses and RNs).2 Professional liability insurance expense RVU comprises the cost of malpractice insurance premiums.8 CMS adds each geographically adjusted component RVU together to arrive at a total RVU for every CPT code (see CPT codes and their corresponding RVUs and payments).8,10 NPs' voices outside of the clinical setting Currently, there is a CPT Editorial Panel that meets three times per year to evaluate codes with input from the CPT Health Care Professionals Advisory Committee (HCPAC). The CPT Editorial Panel consists of 21 representatives including the panel chair, vice chair, 12 members from national medical societies, 2 seats for members of the CPT HCPAC, and 5 seats for other representation such as healthcare insurers. The panel is tasked with updating and modifying CPT codes, descriptors, rules, and guidelines.11 Supporting the efforts of the CPT Editorial Panel is the CPT Advisory Committee, which is comprised of specialty societies, organizations representing limited-license practitioners, and other allied health professionals including NPs.11 The advisor representatives for nurses, including NPs, are nominated by the American Nurses Association (ANA) and approved by the AMA to serve on the HCPAC. The committee members appointed by the ANA serve as advisors on procedure coding and appropriate nomenclature as relevant to the nursing profession. The HCPAC functions as a resource to the Editorial Panel to ensure CPT codes used by NPs and other nursing professionals accurately reflect the latest medical care provided to patients. HCPAC provides input for additional codes, revisions to current code sets, and updates to nomenclature. However, the CPT Editorial Panel makes the final decision on any additions or changes and assigns a code's category. The actions by the panel can result in adding a new code or revising existing nomenclature, referral for further study to a workgroup, postponing to a future meeting, or rejecting the item. - CPT codes and their corresponding RVUs and payments CPT code 2023 work RVU Medicare payment (nonfacility price)∗ 99202 0.93 $65.80-$91.40 99203 1.60 $102.15-$142.95 99204 2.60 $152.93-$215.51 99205 3.50 $202.11-$285.26 99212 0.70 $51.32-$71.15 99213 1.30 $82.72-$115.84 99214 1.92 $117.41-$164.94 99215 2.80 $164.99-$232.52 ∗Varies by geographic area. NPs are clinical experts and have a responsibility to be knowledgeable about the regulations related to coding and billing services, which include any new or changed CPT code sets. Since state regulations vary, changes made to CPT codes may affect NPs differently depending on the location of the practice site. NPs must continuously evaluate the cost and economic impact of a plan of care while accounting for outcomes, as well as validate their contribution to costs averted and costs saved.12 It has been shown that when the quality of care improves, there is a reduction in the cost of care provided.12 In 2021, the CPT code set included 329 changes from the previous year with 206 new codes, 69 revisions, and 54 deletions. The changes to outpatient visit evaluation and management (E/M) services were the most significant for NPs.13 The 2022 CPT code set had 405 editorial changes, including 249 new codes, 63 deletions, and 93 revisions.14 There were significant changes related to technology services, including the addition of five new codes for therapeutic remote monitoring. COVID-19 vaccine and administration codes were assigned, along with a resource to aid NPs in identifying the appropriate combination of CPT codes to use for the type and dose of COVID-19 vaccine provided to each patient.14 Other changes affecting NPs have included guidelines on shared/split billing practices between a physician and a nonphysician provider, which has been put on hold until January 2024 and requires thorough documentation of the time and care provided by each provider to substantiate reimbursement for the patient encounter. In 2023, the CPT code set has seen 393 editorial changes, including 225 new codes, 75 deletions, and 93 revisions. This article cannot discuss all the latest changes; however, they can be found in the CPT® Evaluation and Management (E/M) Code and Guideline Changes full document.15 The final code selection is based on either medical decision-making or total time, and in 2023, these changes have been carried over to the rest of the E/M codes. Therefore, inpatient and ambulatory care E/M codes now share the same set of guidelines. A few additions were made to the medical decision-making table to adjust for the needs of more acute patients in the inpatient setting. Under the “problems addressed” element, “1 stable, acute illness” and “1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care” were added as options within the low complexity level.15 Additional examples were added to the “risk” element of the high complexity level, including “decision regarding hospitalization or escalation of hospital-level care” and “parenteral controlled substances.”15 The previous observation care codes (99217-99220, 99224-99226) have been replaced. The new E/M codes to apply are 99221-99223, 99231-99233, and 99238-99239. All require, at minimum, a medically appropriate history and/or exam as well as straightforward or low-level medical decision-making.15 When using total time on the date of the encounter for code selection, the NP must consider time spent reviewing medical records, caring for the patient (assessment, education, plan of care), collaborating with other providers, and documenting the visit. The appropriate code to apply will vary according to the total time spent. For example, initial hospital inpatient or observation care services require 40 minutes to be spent or exceeded (99221 for 40 to 54 minutes, 99222 for 55 to 74 minutes, and 99223 for 75 to 89 minutes).15 Subsequent hospital inpatient or observation care codes can be used based on medical decision-making or time as well. When using total time for code selection, 99231 is used for 25 to 34 minutes, 99232 for 35 to 49 minutes, and 99233 for 50 to 64 minutes.15 Coding for hospital inpatient or observation discharge is straightforward. Code 99238 is used if discharge time was 30 minutes or less on the date of the encounter, and 99239 is used for discharge time exceeding 30 minutes on the date of the encounter.15 The inpatient or observation consultation codes used for new or established patients (99252-99255) have been updated as well. When using total time on the date of the encounter for code selection, 35 to 44 minutes must be spent to code 99252, 45 to 59 minutes for 99253, 60 to 79 minutes for 99254, and 80 to 94 minutes for 99255.15 The prolonged service code 993X0 or appropriate CMS G-code should be applied whenever the total time exceeds the time appropriated for the highest level of evaluation.15 Shifts in healthcare spending, reimbursement, and patient care make it even more important for NPs to be aware of and involved in reviewing current CPT terminology and service codes. NPs can use their voices to create change in CPT coding that reflects the care being provided to patients. NPs can take active leadership roles by participating in professional organizations and taking surveys asking for expert opinions regarding CPT code changes.12 Another way NPs can be involved is for them to communicate any suggestions for changing existing codes or adding new codes to the HCPAC representatives. In addition, the AMA has an open policy regarding CPT changes and provides on its website an application process for code revisions, which may be submitted directly by NPs.14 All of these actions are vital for NPs to advance their clinical judgment and validate expert competency, which in turn influence quality metrics and cost of care.12 RVUs are established by the Relative Value Scale (RVS) Update Committee (RUC).8 To establish value for the work component of a CPT code, practicing clinicians (NPs, physicians, nurse anesthetists, nurse midwives, and physician assistants) are surveyed by medical organizations to rate the value of work by using magnitude estimation methodology.8 The ANA participates in the RVS Update Process as a member of the Health Professional Advisory Committee, a voting member of the Practice Expense Subcommittee, and primary and co-surveyors and presenters on several CPT codes up for review. This work is critical as it informs the correct valuation of CPT codes, impacting the reimbursement level received by all billing clinicians. The Practice Expense Subcommittee further ensures that the work of clinical staff, which is considered a practice expense for RUC and Medicare reimbursement, is accurately captured.16 NPs' work is represented in the surveys sent by the evaluating medical organizations that justify CPT code values. Developing and revising CPT codes to better characterize NPs' clinical expertise has the potential to demonstrate the value of NPs more accurately. Valid efficiency measures must be tailored to fit NP clinical practices and move away from a one-size-fits-all measure.17 NPs are experts in clinical practice, both in hospital and outpatient settings. NPs' work is more than their clinical expertise: their role after completing a procedure or submitting an office/consult note is to submit charges for their work. It is imperative that NPs practice to the full extent of their education and training to optimize reimbursement. This will ensure that NPs receive the correct RVUs and reimbursement for their quality work and expertise.1 Support from NPs in developing CPT codes and subsequent RVUs for practice is crucial in moving advanced practice forward.1 NPs improving RVUs In the past 2 years, NPs were identified as one of the top provider types billing Medicare for 16 CPT code families (several codes used to bill for a specific procedure) reviewed by the RUC.18 This means that NPs were identified as being a predominant provider performing these procedures.18 In the past 2 years, the ANA surveyed these 16 families of codes. The ANA surveys its members by first identifying its NP members who indicated their area of practice. If the NP typically performs and bills for the CPT code being reviewed, the ANA sends an email to a random sample requesting that NP members complete a survey outlining the requirements of the CPT code, including time, level of difficulty, level of risk, and supplies used throughout the procedure. Of these code surveys, only 1.11% were completed by nurses.18 This means the input used to revise codes primarily submitted by NPs was obtained from physicians and other QHPs (98.89%).18 It is only when NPs provide their opinion by completing these surveys that their clinical expertise and knowledge can be heard by the RUC, CMS, and other paying parties. When NPs engage in these surveys, CPT values are adequately represented, and NPs receive proper recognition and reimbursement. When NPs fail to engage in these surveys or dismiss a request to describe their work, physicians' opinions are heard, and the RVUs for CPT codes may decrease. An improper valuation of a CPT code decreases NPs' total work RVUs, potentially lowering NPs' salaries if they are compensated by their entire work RVUs. Improper CPT valuation also directly reduces the reimbursement for NPs' work. An example of a CPT code family for which NPs were identified as the highest Medicare billing provider type was 99358-59—prolonged service codes. This family of codes was requested to be revalued to ensure proper valuation.19 The ANA partnered with 12 physician medical organizations and sent surveys to be completed by their members that would justify an increase in the RVU value.18 NPs were noted to be the highest utilizers (38.7%) for CPT code 99358, followed by internal medicine (16%) and family medicine (9.4%).19 A total of 20,981 surveys were sent to physicians of 12 medical organizations and ANA members; only 61 surveys were completed, and only 6 of these 61 surveys were completed by NPs.19 The feedback received from medical experts, the majority of whom were physicians despite NPs being the most frequent users of the CPT code, resulted in the RVU value decreasing from 2.10 to 1.80 RVUs.19 This decrease was due to the survey respondents detailing that the providers' work in 99358 had not increased and that the time it took to complete the work was less than previously indicated. For CPT code 99359, NPs were again noted to be the most frequent users (26%), followed by family medicine (15%) and internal medicine (13.3%).19 Again, 20,981 surveys were sent out by the same physician medical organizations and the ANA, but only 54 surveys were completed, of which 6 were submitted by NPs.19 The survey results were compiled and were the base justification for maintaining the current CPT value.19 Without input from NPs, RVUs may not reflect the true value of NPs' work to provide these services and instead only incorporate productivity as a measurement of value.9 At the height of the COVID-19 pandemic, the ANA worked with several other medical organizations to develop more than five CPT families of codes for the newly developed COVID-19 vaccines. During these surveys and collaborations, the ANA's advisors and subcommittee members successfully developed practice expense costs and RVU values that have led providers and facilities to receive proper reimbursement. Another example of NPs' voices being heard as part of the CPT valuation process is the introduction and initial valuation of a new CPT code family (98980-98981) for remote therapeutic monitoring.19 This code was previously billed as a G-code, a code describing a patient's functional ability that is not routinely reimbursed or that is reimbursed at a lower rate by Medicare. The ANA partnered with three other medical organizations and sent out surveys to determine the value of the new CPT code family. Only 7 of the 46 surveys completed were done by nurses.19 Survey data, including nursing expertise, concluded the development of the CPT code and the RVU values for 98980 (0.62 RVUs) and 98981 (0.61 RVUs). Prior to the new CPT codes, these procedures were reimbursed at a rate of $25, whereas the new CPT value is $48.19 Implications for practice NPs have a responsibility to ensure that services rendered are recognized appropriately within CPT codes and that RVU values are accurately assigned. A significant amount of NPs' time is spent providing patient care and documenting encounters; therefore, to safeguard NPs' voices, it is imperative that completing coding evaluation surveys becomes a priority. When NP services are undervalued, the work that is done is not appropriately compensated.18-20 One of the issues for NPs is that there are no set benchmarks for the number of RVUs that NPs should reach in a year. Another concern for NPs is when RVUs are used as the sole measure of productivity and practice achievement.9 Therefore, professional role development for NPs should include knowledge of healthcare reform, payment systems, strengths and limitations related to productivity, and use of RVUs to measure performance.9,17 NPs must provide input on the process of placing a value on new or revised CPT codes based on the time and skill required to perform the service or procedure, since several CPT codes are submitted more often by NPs than by other healthcare providers. The survey data collected are formulated into a recommendation that is forwarded to the AMA and then CMS, which develops the annual Medicare Physician Fee Schedule based on these work value recommendations. Filling out the surveys is an opportunity to provide clinical expertise and be part of the change instead of a bystander to change.