CPT Implementation Guide: Glossary

IMPORTANT NOTE: Descriptions/definitions in this Glossary are for information and educational purposes only, for use within this Implementation Framework, and are intended as an educational guide to help implementers of AMA’s Current Procedural Terminology (CPT®). As such, terms, descriptions, and definitions used here may not be consistent with those published in other AMA publications. Please also note that the names of referenced AMA educational resources, website functions, and website content may change from time to time and that the references in this document may not be updated to reflect these changes. Nothing in this Glossary or Implementation Framework is intended to, or shall be deemed to, modify any document, resource, or other material referenced herein.

Bloom’s taxonomy: A hierarchical ordering of skills used to write learning objectives.

Clinical reporting guidance: The guidelines and parenthetical notes found within the CPT® content that provide instructions on how to accurately report a procedure or service.

Clinician: Physicians/doctors and other qualified health care professionals such as nurse practitioners.

CPT clinical term: A descriptor that describes clearly and specifically the service or procedure performed by a clinician at the point of care. Also called the CPT descriptor.

CPT clinician descriptor: A translation of the CPT long descriptor into terms that describe clearly and specifically the service or procedure performed and used by the clinician at the point of care. Each CPT long descriptor may be translated into two or more CPT clinician descriptors.

CPT® code: Typically, a five-character identifier attached to a CPT descriptor which identifies medical services and procedures performed by clinicians.

CPT code set: A set of clinical terms including long, medium, short, clinician, and consumer friendly descriptors, codes, and thorough documentation and guidelines for their use. The CPT code set is the core of what is described as “CPT content” in this Implementation Framework.  It is available in both electronic form and print formats.

CPT code set editorial process: A physician-driven, open, accurate, and transparent, well-established maintenance process administered by the AMA’s CPT Editorial Panel.

CPT consumer friendly descriptor: A translation of the CPT long descriptor into language that is easily understood by the average patient and caregiver and used by the patient or caregiver through portals of EMRs or hospital information management (HIM) systems. There is one consumer friendly descriptor for each CPT long descriptor.

CPT content: A general term intended to represent the many varieties of information published by the AMA about CPT codes in different publications. In addition to CPT codes, descriptors, and guidelines, “CPT content” includes a robust set of educational resources, including CPT Assistant articles and CPT Knowledge Base publications, among other information and resources.

CPT Guideline: Instructions, such as definitions, that provide clinical reporting information on a block of CPT content. Each section of CPT content has a set of guidelines as do many of the headings.

CPT Implementation Framework Component Dependency: A dependency relationship is a relationship in which one component uses or depends on another component. A dependency relationship may also represent precedence, where one component must precede another. For example, if legacy terms require mapping to CPT terms to use in subset development, the Subsets Component is dependent on the Mapping Component.

CPT Implementation Framework Component Linkage: A description of the relationships between components.

CPT Implementation Framework Component Module: An educational unit within a component.

CPT Implementation Framework Education Handbook:  An education handbook for CPT content adopters, delineating an implementation approach. The handbook consists of 12 components to be used by leaders, teams, and individuals as a resource to assist with implementation. It supports adoption and quality clinical data collection, decreases the complexity and work effort required in implementation, and identifies and supports consistent, reusable documentation, processes, and technical requirements. Serving all audiences, the handbook includes feasibility assessment criteria, CPT content uses, mapping guidance, physician specialty subset examples, and other components needed to move forward.

CPT Implementation Framework Education Handbook Audience: Leaders, managers, and individuals involved in implementation and all other audiences. 

CPT Implementation Framework Education Handbook Component:  One of the 12 components of the education handbook focused on a specific topic. For example, the Assessment of Feasibility Component defines the steps to assess CPT content implementation feasibility.

CPT long descriptor: Full description of the CPT descriptor as listed in the CPT code set and approved by the CPT Editorial Panel.

Electronic health record (EHR): A health record under the custodianship of the health system used in support of multiple care settings.

Electronic medical record (EMR): A record under the custodianship of a health care provider, or providers, that is used in a community physician practice setting. Typical use is by clinicians within a primary care practice or specialist physician practice.

Electronic patient record: In the context of the functional requirements, a “patient record” refers to an electronic patient record in which the CPT content will be implemented.

Feasible: Feasible means the stakeholders collectively agree that the specific issues identified for the project and supplemented with information from interviews with the users of the service descriptions for planning, descriptive analysis, payment, monitoring, and audit and appropriate working group can be satisfactorily addressed through the adoption and implementation of CPT content.

Health information system (HeIS): A record under the custodianship of an integrated delivery network, such as a multi-function health care delivery organization or a health region. The system is deployed broadly across clinical settings and to patients wherever they are.

Hospital information system (HIS): A record under the custodianship of a health care organization. It is used in an inpatient setting such as acute care, continuing care, and long-term care.

Local Term Set: All terms used in a specified area (eg, medical clinic or jurisdiction) by an individual or group of individuals. Includes terms in a standard terminology (both reference terminologies and classification systems) and/or locally defined terms.

Map: The result of the mapping process.

Mapping: The process of associating concepts from one terminology resource to concepts in another terminology resource and defining their equivalence in accordance with a documented rationale and a given purpose.

Parenthetical notes: Instructions that verify the intent of the code(s). The notes are enclosed in parentheses within the CPT content and may be found preceding or following a code listing and within a code descriptor.

Patient portal: Secure online website or mobile app that gives patients/caregivers convenient 24-hour access to their personal health information and medical records from anywhere with an Internet connection via an encrypted, password-protected sign in.

Physician/Doctor: An individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable), who performs a professional service within his/her scope of practice and independently reports that professional service.

Primary data use: Collecting, viewing, and reporting data specific to an individual for the purpose of providing care and services to that person; includes data exchange with other sites for the care of the individual.

Procedure: A medical, surgical, or diagnostic service performed by physicians/doctors and/or other health care professionals.

Relative Value Unit (RVU): The unit of measure for a procedure in a RBRVS system.

Resource-Based Relative Value Scale (RBRVS): A scale of uniform relative values.

Secondary data use: Processing, aggregating, and displaying data for uses other than direct patient care.

Source Term: The term(s) in a local term set that is being mapped to a similar term(s) in another term set. In the mapping process, a Source Term is mapped to a Target Term.

Subset: By definition, a subset is “part of a larger group of related things.” With respect to terminologies, subsets contain a part, or portion, of the content of the full terminology. Subsets are used to filter down the number of terms to those that are relevant for specific use cases.

Target Term: The term(s) in a standard terminology that is associated with a Source Term and considered equivalent or similar in clinical meaning. In the mapping process, a Source Term is mapped to a Target Term.

Term: A word or words that describe a clinical service or procedure.

CPT Implementation Guide