Congr. Comer (KY) writes CMS, raises questions about AMA CPT structure and coding, and fraud and abuse issues.
Comer letter here. Comer press here. STAT PLUS (subsc.) here.
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Could the complexities of US coding systems contribute to healthcare fraud? Certainly something went awry in Medicare - when the Novitas MAC got lost in the forest of CPT genetic codes and assumed some rare costly genetic codes (81408 and others) would never be needed or expected in Medicare. And therefore had no edits on them. Result: One to two billion dollars flowed out through just those unexpected codes (over s i x y e a r s, half under Trump I and half under Biden) before it was stopped.
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RFK Jr has also raised concerns about the US coding system.
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Detailed Summary:
Comer Letter, Comer Press Release, and STAT Article on CPT Codes, AMA, and Fraud
TLDR
Takeaway Message
The Comer documents mark a notable escalation in the politics of medical coding.
CPT has long been criticized as an AMA-controlled proprietary standard, but Comer places it inside the current Washington frame of fraud, waste, abuse, and federal healthcare cost control. His letter asks CMS not only how it polices improper AMA CPT coding, but whether CMS has the authority to simplify or move away from the current CPT-based system altogether. That makes this more than a routine anti-fraud inquiry. It is potentially a challenge to one of the basic operating systems of American healthcare reimbursement.
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House Oversight Chair James Comer has opened a new line of inquiry into the AMA-owned CPT code system,on April 30 asking CMS Administrator Mehmet Oz for a staff-level briefing by May 7, 2026.
The core claim is not simply that fraud exists in Medicare and Medicaid, but that the complexity, proprietary AMA ownership, and annual AMA stakeholder-driven expansion of CPT coding may help create the conditions for improper billing, upcoding, unbundling, and higher federal spending. Comer’s letter asks CMS whether it has data tying improper payments to coding errors or manipulation, what CMS is doing to detect and recover such payments, and whether CMS has legal or operational room to simplify or move away from the current CPT-based system.
The accompanying House Oversight press release amplifies the same themes: federal reliance on a privately maintained coding system, possible lack of transparency, and whether CPT complexity itself drives unnecessary costs. The STAT article adds political context, noting that the AMA’s CPT system has been a recurring target for lawmakers since the early 2000s, but that Comer’s fraud-focused framing is a newer twist. STAT also notes that AMA royalties were a major revenue category in 2024, though the article cautions that the tax-filing category includes products beyond CPT, so CPT-only revenue cannot be isolated from that figure.
[BQ: HIPAA law required HHS to specifiy defined code sets, and since 2000, the outpatient code set has been AMA CPT only.]
1. The Comer Letter to CMS: What It Says
The central document is the April 30, 2026 letter from Rep. James Comer, Chair of the House Committee on Oversight and Government Reform, to CMS Administrator Mehmet C. Oz, MD. The letter frames CPT coding as part of a broader Oversight Committee inquiry into “drivers of rising healthcare costs in federal programs,” including systems that may enable waste, fraud, and abuse.
Comer’s premise is that CPT is not merely a technical billing dictionary. It is a federally mandated infrastructure for Medicare and Medicaid billing. The letter notes that AMA CPT is required for participation in these programs and therefore plays “a central role” in determining how federal healthcare dollars are spent. Comer then draws the inference that the complexity of this system may contribute to improper billing and higher costs.
A major theme is federal dependence on a privately owned system. The letter emphasizes that CPT codes are created and maintained by the American Medical Association, but are embedded into federal payment operations because CMS requires their use. Comer says this raises questions about transparency, cost control, and whether federal healthcare policy is shaped primarily for patients and taxpayers or by entities with incentives tied to continued complexity.
The letter also points to scale. It says the CPT billing system has grown to include more than 7,800 highly granular codes, updated annually through a process “largely driven by external stakeholders.” Comer argues that this level of granularity may create an environment in which billing inaccuracies can flourish.
2. Evidence and Examples Comer Uses
Comer uses several examples to connect coding complexity to program integrity concerns, though the evidence is mostly circumstantial rather than a direct causal demonstration that CPT complexity causes fraud.
- [BQ Medicare uses MS DRG, medical severity DRG, where most DRGs have three levels, uncomplicated, complicated, and major complications [like long ICU stays]. Indeed, most DRGs are major complicated or complicated, a minority are the base DRG or "uncomplicated."]
First, the letter cites HHS OIG findings that from FY2014 through FY2019, hospital stays billed at the highest severity level rose by almost 20%, and that by FY2019 hospitals billed at the top severity level for 40% of all 8.7 million Medicare inpatient cases. This is not strictly a CPT example, since inpatient MS-DRG severity assignment involves diagnosis coding and documentation rather than CPT alone. But Comer uses it as a broader example of how billing systems can drift toward higher payment categories.
Second, the letter cites DOJ’s announcement that False Claims Act settlements and judgments exceeded $2.2 billion in FY2022, with most involving Medicare and Medicaid. Again, this supports the broad point that healthcare fraud and false claims remain major federal concerns, but it does not itself prove that CPT complexity is the root cause.
Third, Comer links the issue to Medicare Advantage risk-adjustment enforcement. He praises the Trump administration for banning certain practices such as unlinked chart reviews, which he says are expected to reduce payments by about $7 billion per year. The letter explains that some MA plans historically submitted diagnoses identified through chart reviews that were not tied to a specific patient visit or claim, thereby increasing payments without documentation of a corresponding encounter.
This MA example is important rhetorically. It shows Comer positioning coding and documentation rules as a major anti-fraud frontier. However, the MA example again concerns diagnosis coding and risk adjustment more than CPT procedural coding. For blog readers, this is worth flagging: the letter moves across several coding domains—CPT, inpatient severity levels, diagnosis-driven MA risk adjustment—under the broad umbrella of “coding complexity” and improper payment.
3. What Comer Wants CMS to Answer
The most operational part of the letter is the six-question briefing request. Comer asks CMS to be ready to address, by May 7, 2026, the following categories:
First, CMS’s assessment of whether CPT coding complexity contributes to improper billing, including upcoding and unbundling.
Second, data on improper Medicare and Medicaid payments attributable to coding errors or manipulation, including trends over time.
Third, CMS’s current steps to detect, prevent, and recover payments associated with improper CPT coding.
Fourth, CMS’s process for evaluating coding patterns associated with high-cost or high-severity billing levels.
Fifth, whether CMS has considered administrative or regulatory actions to simplify coding requirements or reduce opportunities for improper billing.
Sixth, whether statutory, regulatory, or operational constraints limit CMS’s ability to modify or move away from the current CPT-based system.
That last question is probably the most consequential. It asks whether CMS can do anything beyond policing improper claims within the existing system. In effect, Comer is asking whether CMS has the authority to assert more control over coding infrastructure, reduce reliance on CPT, or consider alternatives.
4. The House Oversight Press Release
The House Oversight press release, also dated April 30, 2026, repackages the letter for public messaging. Its headline says Comer is raising concerns that a “complex federal billing system” may be fueling improper payments and rising healthcare costs.
The release repeats the major points: CPT is federally mandated for Medicare and Medicaid; CPT is created and maintained by the AMA; CMS relies on this privately maintained system; and the system’s complexity and lack of transparency may contribute to improper billing and higher costs.
The press release sharpens one point that is somewhat less explicit in the letter: it says the Committee wants to understand whether CMS has authority to assert greater control, reduce reliance on a proprietary standard, or promote alternatives that might lower administrative costs and billing complexity.
This is the key policy hinge. The issue is not just “are doctors coding correctly?” but “should the federal government remain dependent on a privately owned code set for core public payment operations?” For a health policy audience, that is a much larger institutional question.
The press release also repeats the same evidentiary markers: hospital highest-severity billing rose nearly 20% from FY2014 to FY2019 and reached 40% of Medicare inpatient cases; DOJ recovered $2.2 billion in fraud and false claims settlements by the end of FY2022; and unlinked chart review changes in Medicare Advantage are expected to reduce payments by $7 billion per year.
5. STAT’s Contribution: Political Context and AMA Revenue
The STAT article, by John Wilkerson, adds useful political and historical context, but because it is paywalled, a blog summary should be restrained and should not over-extract its content. The article’s main framing is that Comer is taking aim at the AMA’s billing-code role by linking CPT complexity to the current Republican fraud-fighting narrative.
STAT notes that CPT codes are owned by the AMA and are legally required for Medicare and Medicaid billing. It describes Comer’s action as a request for a meeting with CMS officials as part of the committee’s investigation into fraud, waste, and abuse.
The article also emphasizes that Comer’s inquiry targets an important AMA revenue stream. It reports that the AMA receives royalties from use of the codes and that more than half of AMA revenue in 2024, or $301 million, came from royalties. STAT appropriately qualifies that point: the royalty category includes revenue from products unrelated to CPT, so the CPT-specific amount cannot be separated from the public filing.
STAT further observes that lawmakers have criticized CPT and AMA control of the system for decades, including earlier challenges dating back to the early 2000s. The article cites prior political episodes involving Sen. Tom Coburn, Sen. Bill Cassidy, and Kennedy adviser Calley Means, all of whom, in different contexts, questioned AMA influence or its control over coding infrastructure.
The article’s most useful interpretive point is that Comer’s move is a new twist: rather than attacking CPT only as an AMA monopoly or licensing issue, Comer links the code system to fraud, waste, and abuse. That places CPT into a broader Republican argument that healthcare savings can be framed as anti-fraud policy rather than cuts to benefits.
6. What Is Strong, and What Is Less Strong, in Comer’s Argument
The strongest part of Comer’s argument is the observation that CPT is a private code set embedded in public law and public payment systems. That creates a legitimate governance question. If Medicare and Medicaid require CPT, then the federal government is depending on a privately maintained and licensed standard to operate core public programs. Whether one likes or dislikes AMA stewardship, this is a fair subject for congressional oversight.
A second strong point is that coding complexity does create opportunities for mistakes, gamesmanship, and administrative burden. In any payment system with thousands of codes, differential payment rates, bundling rules, modifiers, and documentation thresholds, there will be incentives to code at the highest plausible level. Asking CMS for trend data on upcoding, unbundling, and recovery efforts is squarely within oversight territory.
The weaker part is that some examples in the letter are not strictly CPT examples. The inpatient severity-level discussion largely involves diagnosis coding, documentation, and MS-DRG assignment. The Medicare Advantage unlinked chart-review example involves diagnosis capture for risk adjustment. These are highly relevant to coding and payment integrity, but they are not the same thing as CPT procedural coding. For a technical readership, that distinction matters.
A third caveat is that complexity can cut both ways. Granular codes can enable improper billing, but they can also improve specificity, clinical description, utilization analysis, coverage policy, and payment precision. Eliminating complexity may reduce some gaming but could also create blunt payment categories that produce other distortions. The question is not simply whether CPT is complex, but whether particular areas of complexity are clinically useful, administratively necessary, or primarily rent-seeking.
