CPT in the Crosshairs Again
On April 30, James Comer (R-KY), chairman of the House Committee on Oversight and Government Reform, sent a letter to Centers for Medicare and Medicaid Services (CMS) Administrator Mehmet Oz, asking whether the “complexity and lack of transparency” of the CPT code set may be contributing to improper billing and driving up costs for both patients and taxpayers.
The chairman requested that CMS respond to a series of questions at a staff-level briefing on its oversight of the CPT system as soon as possible, but no later than May 7, 2026.
The CPT code set is developed and maintained by the American Medical Association (AMA). The context for this query is the committee’s interest in rising healthcare costs, the federal government’s reliance on a private entity’s intellectual property for its healthcare billing system, and whether this model and its associated financial incentives are in patients’ best interests.
The letter also raises concerns about potential upcoding by Medicare Advantage (MA) plans, and whether it is a sign of underlying “vulnerability” in the billing system. Potential upcoding by MA plans, outside of this discussion about CPT codes, is an issue that has been previously raised by members of Congress on both sides of the aisle and could be a way for the chairman to gain supporters or generate interest in this issue.
The following questions were posed by the chairman:
CMS’s assessment of the extent to which CPT coding complexity contributes to improper billing, including upcoding and unbundling;
Data on improper payments in Medicare and Medicaid attributable to coding errors or manipulation, including trends over time;
Steps CMS is taking to detect, prevent, and recover payments associated with improper CPT coding;
CMS’s process for evaluating coding patterns associated with high-cost or high-severity billing levels;
Whether CMS has considered administrative or regulatory actions to simplify coding requirements or reduce opportunities for improper billing; and
Any constraints—statutory, regulatory, or operational—that limit CMS’s ability to modify or move away from the current CPT-based system.
Representative Comer is the second Republican in recent months to question the use and role of CPT. As you may recall, Senate HELP Committee Chair Bill Cassidy (R-LA) has made multiple inquiries into CPT and raised concerns over what he has described as a “government-endorsed CPT monopoly” and the amount of money the AMA makes from licensing the product. One stark difference is that Senator Cassidy’s questions were targeted at the AMA, while Representative Comer has reached out to the Trump Administration. Yet both lawmakers are raising similar issues—the appropriateness of using the CPT code set for healthcare transactions.
It is important to remember that the use of CPT codes in healthcare transactions is codified in statute, and historically, CMS has relied on the AMA RVS Update Committee (RUC) for data to establish the valuation of medical services. Although CMS finalized policies in the 2026 Medicare Physician Fee Schedule Final Rule that meaningfully reduced the RUC’s role in setting rates.
Over the years, the use of CPT codes and the RUC’s influence on rate-setting have been challenged, but objections to the role of CPT and the RUC seem especially heightened right now.
An important observation is that the framing of this most recent request is well aligned with the administration’s concerns around fraud and abuse, which could help advance the discussion.
While it is unclear whether the May 7 deadline set by the letter will be met, or even whether the CMS will respond directly to the questions posed, what is clear is that scrutiny of CPT codes and their role in healthcare transactions is not going away – if anything, it is growing.
The CPT/RUC processes have been critical pathways for medical specialty societies and medical practitioners to provide input into code development and the valuation of the services they provide. Reducing the influence of the CPT/RUC processes without an alternative pathway could diminish the voice of medical professionals.
I will keep you posted as this issue develops. Please let me know if you have any questions or wish to discuss.
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For more information and questions, please contact:
Sheila Madhani
Madhani Healthcare Consulting
Email: smadhani@madhani-health.com
Tel: (202) 679-2977