For most of the world, these numbers —99214, 90658, 12002—mean absolutely nothing. But for most of you reading this, they are second language. Introduced by the American Medical Association (AMA) in the 1960’s, the Current Procedural Terminology CPT® codes describe a set of five-digit codes used to delineate medical procedures and services for billing and reimbursement.
The government began adopting them for government program billing in the 80’s, and the popularity of the concept has only grown from there. The AMA maintains control of the codes—and their usage—which is the subject of a recent, potentially precedent-setting lawsuit.
A national nonprofit organization with a stated mission of fighting for healthcare price transparency has sued the AMA over its copyright and licensing fees on these CPT codes. PatientrightsAdvocate.org (or PRA) filed a lawsuit in the Northern District of Illinois, claiming that (payers) plans and providers should not have to pay a trade association to access codes that are incorporated into and required by federal and state law. Additionally, since the codes are included in statute, PRA’s suit says the AMA simply cannot copyright CPT codes since legal precedent forbids any one person from “owning the law.” Therefore, PRA should be able to scan and publish on its website the 2026 CPT codebook and all future editions.
Currently, the AMA charges providers an upfront annual fee as well as an additional per-user fee to use CPT codes in their practices. Companies that use the codes pay licensure fees. Healthcare Dive reports that these practices earn the AMA about $300 million annually.
When asked about the suit, AMA pointed out that it takes some serious work to create and maintain the codes—particularly in a usable format—and that because of this the codes are their private property. The organization described how the process is transparent and involves collaboration from those in the medical, government, and healthcare industry so that it can keep up with innovations and technological advances in the industry.
The founder and chairman of PRA criticized the impact that this “paywall” has on simply understanding medical billing and pricing—much less on the increasingly concerning issue of healthcare affordability that is at the top of the public and Congress’ mind.
As I mentioned, CPT codes have been in use for 60 years. However, there has been an uptick in activity lately questioning the AMA control over something so ubiquitous—and often required—to work in the healthcare industry.
Last year, US Senator Bill Cassidy, a doctor himself and chair of the Senate HELP committee, called the AMA involvement a “government-endorsed monopoly” and an “anti-patient agenda.” He stated that he was actively reviewing the organization and its practices and submitted a list of questions to the AMA, which at last reporting, Senator Cassidy claimed the organization did not fully answer.
Over this summer, an additional congressman wrote to the Centers for Medicare & Medicaid Services (CMS) asking the agency to figure out what legal and administrative hurdles exist for it to leave the current CPT system.
CMS itself joined in the questioning of the organization and their role in government healthcare. In a proposed rule that was released in July, the agency asked for public comment on the practice. The agency asked the public to describe evidence of “harm or challenges” associated with the AMA involvement. It also asked for proposed alternatives to the current system—which would be no small feat.
Now the court will need to decide whether the “uniform language of medicine,” as an AMA spokesperson described CPT, is a language that should be free and open to the public. And to be clear, this is about much more than who owns a five-digit code.
The outcome could determine the fate of a reimbursement system that has become foundational to US healthcare. And require those of us in the industry to learn an entirely new language!
