Category/ Medical Billing

What are CPT Codes? Understanding CPT Codes

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What are CPT Codes

 

CPT is a standardized set of codes that are used to report medical, surgical, and diagnostic procedures and services to a variety of entities, including physicians, insurance companies, and accreditation organizations. Medical bills are billed electronically using CPT codes in combination with ICD-9-CM or ICD-10-CM numerical diagnostic codes.

 

The CPT codes are used to submit claims to federal and private payers when rendering healthcare. As CPT codes provide a detailed description of a procedure or service, they eliminate subjective interpretations of what was delivered to the patient.

 

The American Medical Association (AMA) developed CPT® codes in 1966 to standardize reporting of medical, surgical, and diagnostic services and procedures provided in hospital and outpatient settings.

 

The evolution of healthcare - including the availability of new services and the retiring of outdated procedures - is a major consideration. Every year, the AMA releases new, revised, and deleted CPT® codes, as well as changes to coding guidelines, the AMA also releases smaller updates to various sections of the CPT® code set.

 

Moreover, the AMA updates CPT® terminology or medical language to reflect advances in medicine. Though the AMA owns the copyright to CPT®, it invites participants to contribute to the ongoing maintenance of the code set and welcomes feedback on the codes and code descriptors.

 

 

 

 

Understanding CPT® codes

CPT® codes are composed of five characters. In general, codes are numeric, but some codes include a fifth character, such as A, F, T, or U. These are some examples:

92526       Oral function therapy

0638T       Ct breast w/3d bi c-/c+ 

 

 

Using CPT Codes Correctly

Using the incorrect CPT codes when invoicing for medical services can result in rejected claims and various complications. It is crucial to utilize the appropriate codes to avoid these issues accurately.

If you are still determining the appropriate CPT code to utilize for a specific procedure or service, it is advisable to seek guidance from a medical coding specialist.

 

How to use CPT codes

To invoice for medical services, healthcare providers are required to utilize the appropriate CPT code for each procedure or service they administer. The suitable CPT code is determined based on the nature of the procedure or service, its level of complexity, and the patients medical condition.

 

CPT® Code Types: A Quick Guide

Providers assign codes to every service or procedure they perform. It even includes codes for services and procedures not specifically named in another CPT® code, called unlisted codes.

The AMA has organized CPT® codes logically by classifying them into three types based on the wide range of services and procedures they cover:

CPT® Category I: Codes commonly used by providers to report their services and procedures comprise the largest body of codes

CPT® Category II: Additional tracking codes used in performance management

CPT® Category III: Emerging and experimental codes for reporting services and procedures

 

CPT® Category I:

Most CPT® codes are in Category I. There are a variety of existing services and procedures that are widely used and, where appropriate, approved by the Food and Drug Administration (FDA).

 

In general, Category I codes, which are typically represented by five characters, are arranged numerically. Codes are resequenced in one discrepancy from the expected order. In order to facilitate quick access to related codes - and help coders select the best codes - the AMA groups similar codes together. Resequenced codes occur when a new code is added to a family of codes, but there is no sequential number assigned to it.

 

Another exception to numerical code order involves evaluation and management codes (E/M codes). Although E/M codes begin with 9, they are printed first in CPT® code books, as you can see below in the code outline for Category I. E/M services are among the most frequently reported healthcare services, so the AMA chose this order. As with resequenced codes, this arrangement is intended for coding efficiency.

 

Codes for CPT® Category I fall into six main categories:

1.    Evaluation & Management (99202–99499)

2.    Anesthesia (00100–01999)

3.    Surgery (10021–69990) The code range is further divided into smaller groups by body area or system

4.    Radiology Procedures (70010–79999)

5.    Pathology and Laboratory Procedures (80047–89398)

6.    Medicine Services and Procedures (90281–99607)

 

CPT® Category II:

Four numbers and the letter F make up Category II codes, which providers can assign in addition to Category I codes. There is no reimbursement associated with Category II codes, unlike Category I codes.

 

The CPT® code book typically places Category II codes after Category I codes. These codes are listed as follows:

1.    Composite Measures (0001F–0015F)

2.    Patient Management (0500F–0584F)

3.    Patient History (1000F–1505F)

4.    Physical Examination (2000F–2060F)

5.    Diagnostic/Screening Processes or Results (3006F–3776F)

6.    Therapeutic, Preventive, or Other Interventions (4000F–4563F)

7.    Follow-up or Other Outcomes (5005F–5250F)

8.    Patient Safety (6005F–6150F)

9.    Structural Measures (7010F–7025F)

10.  Nonmeasure Code Listing (9001F–9007F)

 

CPT® Category III:

Category III codes, characterized by four numbers and a letter T, usually follow Category II codes in the code book. Categories III codes are temporary codes used to identify new technologies, services, and procedures.

 

In Category III, temporary codes describing new services and procedures can remain for up to five years. They must meet Category I criteria, including FDA approval, evidence that the procedure is widely practiced, and evidence that it has proven effective. A new Category I code will be assigned to them. Providers can also eliminate Category III codes if they do not use them.

 

The AMA releases new or updated Category III codes semiannually via their website but publishes the deletions of Category III codes with the full list of temporary codes annually.

 

 

 

Tips for using CPT codes correctly

Make sure to utilize the most current CPT codebook. CPT codes undergo annual updates, so it is crucial to utilize the most recently published codebook to guarantee the accurate usage of codes.

 

When choosing a CPT code, it is crucial to be as precise as possible. The level of specificity in the code directly affects the accuracy of the reimbursement.

 

If you are still determining which CPT code to utilize, seek advice from a specialist in medical coding.

 

Why are CPT codes important?

CPT codes play a crucial role for multiple reasons. They ensure accurate payment to healthcare providers, minimize billing mistakes, and streamline the claims procedure.

 

Here are some tips for understanding CPT codes:

It is vital to grasp the different classifications of CPT codes. CPT codes are categorized into six groups: Evaluation and Management (E/M), Anesthesia (A), Surgery (S), Radiology (R), Pathology and Laboratory (P), and Medicine (M).

 

Make sure to review the CPT codebook thoroughly. The codebook contains comprehensive explanations for every CPT code. It is crucial to carefully read and comprehend the code descriptions to grasp the specific requirements for each code.

 

To effectively choose CPT codes, it is essential to follow the guidelines provided by the American Medical Association (AMA). These guidelines, published by the AMA, serve as a valuable resource in selecting the appropriate codes for your services.

 

Seek guidance from a professional in medical coding. If you are uncertain about the appropriate CPT code to utilize, seek advice from an expert in medical coding.

 

Here are some additional tips for understanding CPT codes:

Consider the complexity of the procedure or service. The more complex the procedure or service, the higher the CPT code will be.

 

Consider the patient condition. The patients condition can also affect the CPT code that is used. For example, a CPT code for a complex procedure performed on a patient with multiple medical conditions will be higher than a CPT code for the same procedure performed on a patient with no other medical conditions.

 

Consider the anatomical site of the procedure or service. The anatomical site of the procedure or service can also affect the CPT code that is used. For example, a CPT code for a complex procedure performed on the head or neck will be higher than a CPT code for the same procedure performed on the extremities.

 

By understanding these basic principles of CPT coding, you can ensure that you are using the correct codes for your services and that you are getting reimbursed accurately.