Current Procedural Terminology (CPT) code – The CPT (Current Procedural Terminology) is a set of codes, descriptions, and guidelines used by doctors and other health care providers to describe procedures and services. A five-digit code is used to identify each procedure or service.
The American Medical Association (AMA) modernizes the CPT manual once a year, and pain management professional specialty societies contribute to the ongoing development and maintenance of CPT codes. There are extensive coding requirements for services and procedures in the CPT manual, and providers are accountable for knowing how to report and document CPT codes for their services accurately.
What are the Different Types of CPT Code?
Electronic medical billing requires CPT codes and ICD-9-CM or ICD-10-CM numerical diagnostic coding. Moreover, CPT codes are divided into 1, 2, and 3. The American Medical Association owns the trademark rights to the acronym CPT.
Category 1: Contemporary Medical Procedures & Practices
Procedures and modern medical practices in Category 1 are the most commonly used ones. Under this, a procedure or service that has been approved by the Food and Drug Administration (FDA) is performed by healthcare professionals across the country. Also, this has been proven and documented and is referred to as a Category 1 procedure or service.
Codes in Category 1 are divided into six categories:
- pathology and laboratory
- Evaluation and management
Category 2: Clinical Laboratory Services
Additional tracking codes used for performance measurements to help collect information about the quality of care provided make up the Category 2 CPT code set. Medical code sets like this are optional and do not replace Category 1 codes.
Category 3: Newly developed products, services, and methods
Temporary CPT codes for new technologies, services, and procedures are included in the Category 3 CPT code list. Categorized as medical services that do not have FDA approval or established clinical efficacy, these CPT codes differ from those in the Category 1 medical CPT code list.
The service or procedure needs to be involved in ongoing or planned research to be eligible. These CPT codes are designed to assist researchers in keeping tabs on new technologies and emerging services.
Frequently Used CPT Codes
In medical billing, the six most frequently used CPT codes include the ones listed below:
- Subsequent hospital care codes
- Emergency department visit codes
- New patient office visit codes: patients who have never been seen by a physician in the same specialty and within the same group in the last three years are billed using new patient office visit codes
- Established patient office visit codes: codes used to bill for patients who have been seen by a physician in the same specialty and within the same group over the past three years
- Hospital admission codes are used to bill for patients admitted to a hospital
- Office consultation codes: Mostly used when a patient seeks a physician’s opinion from another doctor
Getting Acquainted With CPT Codes
There is a lot for newbie CPT coders to take in when it comes to rules, notes, code descriptors, norms, and recommendations.
As you might expect, an understanding of anatomy and medical language is required for procedural coding. Suppose a technique has multiple variants, each with a somewhat different description. In that case, it is necessary to be able to read the clinical documentation and the code description to determine which code descriptor best describes the procedure as done by a physician. Providers can use CPT codes from any section of the codebook. Therefore they must have a broad grasp of anatomy and medical terminology.
More importantly, the codes a provider can use are not restricted by the specialization in which they work. For instance, a primary care coder must assign an appropriate X-ray code if a primary care physician reads a radiology X-ray, although X-ray codes are listed under radiology.
Understanding & Using the Codes for CPT Coding
There are specific rules provided by the American Medical Association (AMA) for CPT coding, including information on when and how to assign codes and when and how not to report specific codes together.
Before assigning a CPT code, it is critical to understand the CPT criteria in each section, subsection, subheading, category, and subcategory.
Therefore, while calculating and reporting CPT codes on medical claims, consider obtaining suitable training and credentialing to ensure that you are adequately prepared. Make sure your employer gets the most money possible by using this method.
Medical Necessity Assessment
If a patient’s diagnosis does not support the service or operation provided by a healthcare professional, the provider will not be reimbursed by the insurance company. Medical necessity is the term used to describe this rationale, and this is where ICD-10-CM coding and CPT code intersect (and HCPCS Level II).
Every reimbursement claim must include a code for the treatment or procedure, such as a CPT code and an ICD-10-CM code(s) that indicate the patient’s diagnosis to the highest degree of specificity.
Accordingly, an ICD-10-CM code (diagnosis) must be established (service or procedure). For example, when a patient comes into a doctor’s office complaining of stomach pain, the physician does a physical examination to determine the cause. The diagnosis of stomach pain warrants the need for an examination (service).
Medical Coding Career Training
Even though medical coding is complex, you don’t need a four-year degree to start the field. If you work in a healthcare environment, you may be exposed to the complexities of CPT, ICD-10, and HCPCS Level II coding over time. Still, certification is a good idea. Additionally, certification might enhance one’s career and earning potential by verifying one’s proficiency in coding.
The CPT, ICD-10-CM, and HCPCS Level II code books are essential for anyone who works as a medical coder or studies to become a certified professional coder. An ICD-10-PCS codebook is also required for inpatient coding at a hospital.
Working medical coders often use software with procedure code lookup to quickly access a list of CPT codes and descriptions, but these tools are also available to students. The key to successful coding is to stay up-to-date with the most recent code sets.
For more than 50 years, doctors and other healthcare professionals have used CPT to share information about their procedures with their colleagues, patients, hospitals, and insurance companies. Using the CPT coding system, medical providers all around the country have a standard method for accurately and efficiently categorizing medical services.