Scott D. Duncan, MD, MHA

Ten years ago, “That Little Ol’ Band from Texas,” ZZ Top reworked a 1989 rap song titled “25 Lighters” into a minor hit, “I Gotsta Get Paid.” Like many other musical scores, “I Gotsta Get Paid” is structured using a three-chord progression, in this example, D, C, and A, with variants thrown in for interest. This article will examine a common structure for songwriters and relate it to Current Procedure Terminology (CPT®). 

CPT® code categories use a “three-code” structure, which includes: (1) 

• Category I codes – These codes are for reporting services or procedures and devices and drugs required for services or procedures, which are billable for reimbursement. An example of this code in neonatology would be 99468, the initial day of critical care for the evaluation and management of a neonate, 28 days or lessT 
• Category II – These codes are for reporting performance measures, utilized by the Performance Measures Advisory Group, which is populated by members from the American Medical Association (AMA), and Centers for Medicare and Medicaid Services (CMS), among others. An example would include 3294F, Group B Streptococcus screening documented as performed during week 35-37 gestation. 
• Category III – These are temporary codes for emerging technology, services, or procedures, which either progress to Category I codes, are renewed for an additional five years, or are removed. The most recent example in neonatology is found in cooling for hypoxic-ischemic encephalopathy. 

The code set is maintained and revised by the CPT® Editorial Panel, which the AMA Board of Trustees appoints. The Editorial Panel is supported by CPT® Advisors representing the various medical specialties, including the American Academy of Pediatrics. The CPT® Advisors inform the Editorial Panel by proposing revisions, additions, and changes to the CPT® code set. (1)

In neonatology, most providers will deal primarily with Category I CPT® codes. 

Had ZZ Top simply recorded a new version of “25 Lighters”, it would have been referred to as a ‘cover version’; however, when modified and changed, it is called a derivative work, and the new song must be reviewed and approved by the original artist. In this case, the original artists of “25 Lighters” had passed away; subsequently, the estate reviewed and approved the version, “I Gotsta Get Paid.” 

Establishing a proposed new CPT® code follows a similar, related pathway. Consider the cooling codes, for example. Recognizing new technology and procedures, The CPT® Editorial Panel established the temporary Category III codes 0260T and 0261T for ongoing evaluation for total body and selective head cooling for hypoxic-ischemic encephalopathy, respectively. By 2014, the temporary codes for cooling were replaced with +99481 total body systemic hypothermia in a critically ill neonate per day and +99482 selective head hypothermia in a critically ill neonate per day, with the plus (+) designation signifying that the code is added to the primary service code for the day. By 2015, these codes were replaced with the current 99184, which recognizes the increase in initial work of the physician in commencing cooling. 

One of ZZ Tops’ early hits, “LaGrange,” uses this familiar three-chord structure A-C-D. Yet, musicians may create tension and emotional reaction by altering the chord structure and timing, creating a degree of harmonic dissonance. Further, there can be dissonance, tension, and emotional reactions as some of the codes we choose are not always “black and white”! Within CPT®, our code structure is aligned to the Relative Value Unit (RVU) assigned to the code. The physician payment system or resource-based relative value scale (RBRVS) is structured on the principle that physician payments should vary with the costs of resources used for providing those services. The individual CPT code is based on Relative Value Units (RVUs) and built around three (chords) components (2): 

• Physician work (PW) – The majority of the total RVU is encompassed by physician work, which includes the time it takes to perform the service, technical skill, physical effort, mental effort, and judgment. A portion also includes stress due to the potential risk or harm to the patient. This component is updated annually and focused on changes in medical practice. 
• Practice expense (PE) – This component addresses the costs of maintaining a practice and has differing values based upon whether the service was provided in a healthcare facility (i.e., hospital), or non-facility, the latter rare in neonatology. Examples of consideration in practice expense calculations in a facility setting might include direct costs such as equipment, supplies, and nonphysician staff costs and indirect (allocated) costs. 

Professional liability insurance (PLI) – This is typically the least of the components making up the RVU values for the code and represents professional liability expenses. 

The RVUs for these components are updated annually, based on recommendations from the AMA/Specialty Society Relative Value Scale Update Committee (RUC). 

In songwriting, harmonic dissonance can be accomplished by adding different chords, altering the chord progression, or utilizing a different series of note progressions. For example, sharps (#), sevenths (7), or minors (m) are frequently added to the melodic line. Similarly, to complete the construction for a CPT® code for an individual area, region, or state, a geographical adjustment, the geographic practice cost index (GPCI), is included in the calculation for each component. For example, the cost of physician work and practice expense is higher in Houston, TX (the origin of ZZ Top) than in Louisville, KY (PW GCPI 1.032 vs. 1.000; PE 1.029 vs. 0.869), yet the cost of professional liability is less (0.550 vs. 0.827). (3) Finally, the total RVUs are multiplied by the conversion factor (CF), which is adjusted to maintain budget neutrality. The proposed CF for 2023 is $33.28, allowing for the expiration of the 3% increase in 2022. (4) This will be the lowest CF in the last 25 years, from a peak CF of $38.0870 in 2008. (5) 

To complete our code, here is an example of CMS payment for CPT® code 99468 in Houston for 2022. (You may need to consult with a statistician!) 

[(PW 18.46 RVU * 1.032 GPCI) + (PE 6.80 RVU * 1.029 GPCI) + (PLI 1.24 RVU * 0.550 GPCI)] * CF 2022 $34.61 = $925.13. 

Note that CMS has a search function that will allow for a search of the individual RVUs and other components of the physician fee schedule. (6) 

This ongoing series of coding articles first appeared in December 2019 with an article titled “Neonatal Coding and Documentation: The History.” (7) The article reported a brief history of Current Procedural Terminology and the International Classification of Disease (ICD), noting that CPT® codes are “descriptive and report procedures and medical services performed by healthcare professionals.” Similarly, the ICD code utilizes a common language for diagnosis. The history of CPT® coding, including neonatology, is full of covers and derivatives, and neonatology has benefited from those who sought to simplify, standardize, and value our current codes. 

“I just got paid today 

Got me a pocket full of change.” 

Just Got Paid (ZZ Top) 

Song by Bill Hamm and Billy F Gibbons 

Author’s Note: Thanks to Gilbert I. Martin, MD, for editorial comment and lyrical inspiration. As Dr. Martin “notes,” music and medicine have always been related. He poses the question and suggests: Can we relate the codes we choose in the same fashion? Can we alter, modify well-known songs, or create lyrics that can be interposed? We are all familiar with Somewhere Over the Rainbow, recorded by Judy Garland for the 1939 film “The Wizard of Oz.” 

Somewhere over the Rainbow 

Way up high 

There’s a land that I hear of 

Once in a lullaby…. 

Now with the derivative, code-related lyrics, authored by Gil Martin, MD, “Learning About CPT.” 

Someday, choosing a code 

Will set me free 

Why must I add to my frustration 

Learning about CPT…. 

Thanks, Gil. 

References: 

1. American Medical Association. CPT® overview and code approval. American Medical Association, Accessed August 16, 2022, https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval 
2. American Medical Association. RBRVS Overview. American Medical Association, . Accessed August 16, 2022, https://www.ama-assn.org/about/rvs-update-committee-ruc/rbrvs-overview 
3. eMDs. Geographic Practice Cost Indices (GPCI). eMDs. Accessed August 16, 2022, https://emds.com/gpci/ 
4. Center for Medicare & Medicaid Services. Calendar Year (CY) 2023 Medicare Physician Fee Schedule Proposed Rule. Center for Medicare & Medicaid Services, Accessed August 16, 2022, https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule 
5. American Medical Association. History of Medicare Conversion Factors American Medical Association, August 16, 2022, Accessed August 16, 2022, https://www.ama-assn.org/system/files/2021-01/cf-history.pdf 
6. Center for Medicare & Medicaid Services. Search the Physician Fee Schedule. Center for Medicare & Medicaid Services, Accessed August 16, 2022, https://www.cms.gov/medicare/physician-fee-schedule/search 
7. Martin GI. Neonatal Coding and Documentation: The History. Neonatology Today. 2019;14(12):65-66. 

Disclosure: The author has no disclosures.