Court OKs collaboration on CPT codes

A company that had a CPT code request for a product denied maintains the process amounts to conspiracy.

By — Posted Sept. 3, 2007

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Organized medicine scored a legal victory in a decision physicians say upholds the CPT coding process and protects medical societies' role in it.

The U.S. District Court for the Northern District of Georgia tossed out antitrust claims that the American Medical Association and the American Urological Assn. conspired to deny a category I CPT code for Neotonus Inc.'s patented device to treat female urinary incontinence.

Neotonus alleged in a 2004 lawsuit that the AUA influenced the AMA CPT Editorial Panel -- which reviews, sets and modifies CPT codes --so its therapy would not replace more profitable procedures already in use. Neotonus claimed that the panel's denial cost the company $20 million.

But the court found ample evidence that the AMA panel -- composed of volunteer physicians -- thoroughly and independently researched Neotonus' technology and related studies before concluding there was not enough peer-reviewed research to show the treatment was effective. That requirement, among others, is necessary for a category I CPT code, used to describe services widely performed by doctors.

"This lawsuit appears to be an attempt on the part of Neotonus to have a federal court second-guess the medical expertise and opinions of the 17 Editorial Panel members and numerous medical specialty societies and payers," the August opinion states.

Physicians praised the ruling, saying it preserves a system that accurately reflects the effective care doctors provide to their patients.

AMA Board of Trustees Chair Edward L. Langston, MD, said the organization's CPT coding process "is fair and impartial, and the judge's ruling affirms this fact."

Meeting standards for CPT code development depend on specialty societies' expertise, said the AUA's general counsel, Michael A. Pretl. "It's necessary for people like the AUA to assist in recommendations and approval and do some of the legwork in studying new technologies."

The court agreed, saying "it is not inappropriate for the Editorial Panel, when tasked with reviewing an application for some type of medical therapy, to seek the advice of the respective medical specialty societies most knowledgeable or experienced in the relevant field."

Pretl said public and private payers rely on the CPT structure. "If the court found us liable, it would have caused the whole system to be re-examined, and physicians would be reluctant to participate."

Neotonus, though, said the AMA and AUA's actions have denied patients access to a beneficial alternative to other treatments. The company plans to appeal the court ruling.

Mark E. Nagle, Neotonus' attorney, said "the effectiveness of the technology was established and is being used," including at Emory University's Continence Center in Atlanta.

In 2000, Neotonus applied for a category I CPT code for its pelvic floor therapy system after physicians using it reported difficulty getting reimbursed, legal documents show.

The AMA Editorial Panel and its advisory committee reviewed the company's submitted research and nearly unanimously found it insufficient to warrant the code.

During the process, which involved several appeals by Neotonus, the AMA panel sought additional input from the AUA, among other specialty societies. The AUA reviewed Neotonus' submissions and conducted a separate study but still found no established benefits from the therapy.

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Case at a glance

Did medical societies conspire to deny a CPT code for a new treatment?

A federal district court said no and found the CPT code evaluation process impartial. The plaintiff plans to appeal.

Impact: Organized medicine says the liability threat could have jeopardized the CPT process and medical societies' willingness to participate in it. The company involved says the collaboration prevents competition from new therapies.

Neotonus Inc. v. American Medical Association and American Urological Assn., U.S. District Court for the District of Georgia, Atlanta Division

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