CPT® codes (short for Current Procedural Terminology) are a universal set of medical codes used by healthcare facilities to describe medical, diagnostic, and surgical procedures for insurance companies, healthcare payers, government entities, medical research, and provider records. Every time you visit a hospital or medical office, your medical records are updated using medical codes, which are often CPT® codes. Creating medical claims using the correct codes is important, so the insurance companies can pay their portion of the patient bill correctly. CPT codes were first created by the American Medical Association (AMA) in 1966 and are currently maintained and updated by the CPT® Editorial Panel, appointed by the AMA.
CPT codes are an integral part of claims processing, medical billing, administrative management, and electronica health records (EHR). The same codes are used by all healthcare providers to reduce errors and increase accuracy.
What Are CPT® Codes?
CPT codes give physicians and healthcare professionals a universally understood language for recording medical procedures and services during any patient visit. The uniformity of a coding system ensures greater accuracy for claims processing, internal records, and insurance purposes. This terminology is accepted everywhere in the US and describes every type of medical and surgical procedure.
Every CPT code is a five-digit codes which can be either numeric or alphanumeric. Whenever a new healthcare procedure appears, the CPT Editorial Panel will evaluate the situation and add a new code.
There are four types of medical codes, each with a distinct category.
Category I
Category I CPT codes represent widely performed medical procedures and services. These numerical codes range from 00100–99499 and are organized into sub-categories based on the type of procedure or service. Similar codes are usually arranged in a sequence. If a new code is added to a group of codes but no sequence is available, it may be non-sequential numbering.
Category I codes are universally accepted by insurance companies, government agencies, and the US Food and Drug Administration (FDA). The CPT Editorial Panel releases new codes each year.
There are six main sections of CPT Category I codes:
· Evaluation and Management (99202–99499)
· Anesthesia (00100–01999)
· Surgery (10004–69990) – subcategories by body part or type of surgery
· Radiology (70010–79999)
· Pathology and Laboratory (80047–89398)
· Medicine (90281–99199, 99500-99607)
Category II
Category II CPT codes are optional tracking codes used for performance measurement. These codes are supplementary, and help with data collection about patient outcomes. They are not meant to replace Category I codes; Category II CPT codes are not linked to reimbursement.
All Category II CPT codes are alphanumeric, consisting of four numbers and ending with the letter “F”. Here are some subcategories for Category II codes.
· Composite measures (0001F–0015F)
· Patient management (0500F–0584F)
· Patient history (1000F–1505F)
· Physical examinations (2000F–2060F)
· Diagnostic/screening processes or results (3006F–3776F)
· Therapeutic, preventive, or other interventions (4000F–4563F)
· Follow-up visits or other outcomes (5005F–5250F)
· Patient safety (6005F–6150F)
· Structural measures (7010F–7025F)
· Non-measure code listing (9001F–9007F)
New Category II codes are released three times a year.
Category III
All Category III CPT codes are temporary codes for new and emerging procedures, technology, and services. These codes are for data collection, assessment, and in limited cases, payment for eligible services which do not meet the requirements for Category I codes.
The Category III CPT codes are five-digit codes of four numbers, followed by the letter T. These codes cover procedures which are not widely performed by healthcare professionals, or which might not have FDA approval, or have unproven medical effectiveness.
Category III codes may be reassigned to Category I if they receive FDA approval, or if clinical tests prove the procedure to be highly effective.
The list of Category III codes is updated twice a year by the AMA on their website.
Proprietary Laboratory Analyses (PLA)
The newest category of code, these are for proprietary clinical laboratory analyses. These can be provided by a single “solesource” laboratory, or licensed to several FDA-approved labs. This category includes but is not limited to Advanced Diagnostic Laboratory Tests (ADLTs) and Clinical Diagnostic Laboratory Tests (CDLTs).
What’s the Difference Between CPT and ICD Codes?
CPT codes are just one part of medical coding. The main difference between CPT codes and International Classification of Diseases (ICD) codes are CPT codes describe procedures and treatments, and ICD codes, specifically IC-10-CM, are for recording diagnoses. In short, CPT are procedural codes, ICD are diagnostic codes.
Anything that is a treatment, procedure or service is a CPT code. Anything that is a diagnosis or reason for the doctor’s visit is an ICD code. Putting these codes together in a medical claim or electronic health record tells the story of why the patient visited the medical office and what happened.
How CPT Codes are Used in Medical Billing and Coding
CPT codes directly affect how much a patient will pay for the medical care they receive.
Provider offices, hospitals, and other medical facilities are strict about how CPT coding is done. They hire professional medical coders or coding services to make sure that services are coded correctly.
The accuracy of medical coding and CPT codes has a direct effect on the amount a patient will pay, and on the revenue cycle of the medical office.
Medical offices, hospitals, and healthcare facilities employ medical coders to encode the patient visit. This record of the visit is verified by the medical billing and coding specialists to ensure the correct CPT codes were used. This transcript is turned into a claim which is submitted to the insurance payer. The claim is processed by the payer, using the CPT codes to figure out the amount to pay the medical office. The remainder is the patient responsibility. Many insurance companies and government agencies use medical coding data to identify trends and to predict future medical costs. In the bigger picture, this information is also used for planning Medicaid and Medicare annual budgets.
What is the Most Used CPT Code?
99213 is the most frequently used CPT code, according to a report by Definitive Healthcare. This corresponds to a 20 minute outpatient office visit.
Where You Will See CPT Codes
You might see medical codes like CPT codes on paperwork you receive from a medical office or hospital. When you’re done with an appointment and you get discharged, you may see a list of services and procedures you received. These are usually CPT codes and ICD codes. Similarly, you’ll often see a list of CPT codes on the initial medical bill you get in the mail after a visit. Your health insurance company may also send you a letter with explanation of benefits, and what they paid for a doctor’s visit.
Become a Medical Billing and Coding Professional in About 10 Months
Have you been thinking about starting a new career as a medical billing and coding specialist? The program at Campus allows you to earn your certification in medical billing and coding in 42 weeks. You will be prepared to earn your Certified Medical Reimbursement Specialist (CMRS) certification at our Sacramento college. If you have questions, we have answers. Our helpful admissions staff is available at: (916) 339-1500. Call us today or request more information.