Around 90% of the total population of the United States is covered by health insurance programs, and this statistic is about 2019. As the population raised, the insured coverage saw a further hike. For the same reason, health practices designed their services in such a way that it facilitates both patients and insurance companies. One of the initiatives to update health services was the use of CPT medical codes in hospital bills.
CPT codes are numeric codes that specify a certain health service taken by a patient. When included in a bill, it helps insurance payers identify what services were taken by their clients and how much they have to pay to the hospital according to the coverage plans. With the help of CPT medical codes, hospitals define a patient’s service details in a bill and get their reimbursement from the insurance payer.
Since CPT codes have been in implementation for a long time, it has now been separated into 3 categories. But let’s first look at a detailed overview of CPT medical codes, their owners, and implementation.
What Are CPT Medical Codes?
CPT codes, short for Current Procedural Terminology codes, are a standardized system utilized by healthcare professionals, including physicians, non-physician practitioners, outpatient facilities, and laboratories. These codes play a crucial role in specifying the services rendered in a patient’s medical bill, enabling insurance companies to accurately identify and reimburse for the healthcare services utilized.
The oversight and management of CPT medical codes fall under the purview of the American Medical Association (AMA). In 1966, the AMA introduced CPT codes as a means to categorize and distinguish medical, surgical, and diagnostic services provided by healthcare practices.
Each CPT code consists of a five-digit alphanumeric combination, primarily comprised of numbers. However, in certain instances, an alphabet may be included. The unique combinations of these codes serve to classify specific healthcare treatments. These codes are integrated into medical bills alongside other code types, such as ICD-10-CM, which further elucidates the medical necessity for the provided treatment.
The CPT Code Innovators
CPT medical codes have been in operation for 50 years and act as a mode of communication between health practice and insurance payers. CPT editorial panel is in charge of modifying the codes to incorporate evolving technology and industry needs to meet standard criteria.
Experts working on the editorial panel are volunteers representing specific areas of the health industry. They develop new code sets. They also ensure to pass code amendments through evidence-based review in order to make them eligible to use.
This editorial panel consists of advisors and physicians nominated by national medical specialty societies. The primary role of a CPT advisor is to:
- Advise editorial panel on coding procedures and nomenclature by providing revision of the code set
- Work with other stakeholders to make them consider addition and upgrade to CPT
- Educate other members to make them realize the importance and benefits of using CPT codes
CPT medical editorial panel holds 3 meetings per year to examine the application of new codes and revision of existing ones. Anyone who wishes to attend the meeting can apply and be part of the discussion.
3 Categories Of CPT Codes
After the introduction of CPT medical codes by AMA, the creation and management of code sets are handled through a transparent process conducted by the CPT editorial panel. This program ensures constant upgrades and editions in the existing code after analyzing industry trends and healthcare needs.
Now CPT falls under the following three categories:
CPT Category 1: Contemporary Medical Practices
This category involves contemporary medical services and procedures that are performed extensively. Codes if widely applied in the health sector, are approved by the Food and Drug Administration (FDA) and included in category 1. This is the broadest category, that involves a 5-digit code.
CPT category 1 has the following sub-sections:
- Evaluation and management
- Pathology and laboratory
- Medicine
- Anesthesiology
- Surgery
- Radiology
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CPT Category 2: Laboratory Services
Category 2 of CPT medical codes is supplementary. It helps in measuring the performance of health practice. It represents a quality of delivered healthcare service. Though this category also contains alphanumeric digits, these codes have 4 numbers and the letter F at the end.
Category 2 codes are optional to be used in medical bills, and neither does it is a substitute for Category 1. That means medical coding can be done accurately without the use of CPT 2 category codes.
CPT Category 3: Evolving Technologies And Health Services
These are temporary types of codes assigned to emerging technologies, health procedures, and services. These codes help track new services that are not widely operated by health practices. It is mostly used for data collection and payment for new services and for those specific functions that do not meet Category 1 criteria.
Category 3 codes comprise 4 number digits and a letter T. These codes may remain in this category for up to 5 years, during which its application is observed. If the service associated with the code shows its huge implementation in the health sector and efficiency in curing the patients, it is approved by FDA and sent in category 1.
If a certain Category 3 code is not used much by health providers, they are eliminated from this category.
What Are The Commonly Used Codes?
CPT codes where help health practices and insurance companies identify a health treatment, these codes show their different purposes as well. That is, CPT medical codes are used for the following:
New patient visit CPT medical codes
Codes used in medical bills of those patients that have never taken a service from a certain physician under a specific facility for the last 3 years.
Established patient codes
Used in medical bills of those patients that have taken a health service from a certain physician under a specific facility for the last 3 years.
Initial healthcare for new or established patient codes
Used in medical bills of patients that are admitted to the hospital.
Subsequent healthcare codes / Emergency visit codes / Office consultation codes
Codes used in billing those patients that consult a physician upon the suggestion of another physician.
While the range of CPT medical codes is extensive, there are several commonly used CPT codes that healthcare providers encounter frequently. Let’s explore some of these codes and their corresponding procedures:
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Evaluation and Management (E&M) Services
- CPT code 99201-99499: These codes encompass a wide range of services such as office visits, consultations, and hospital visits.
Diagnostic Procedures
- CPT code 85025: Complete Blood Count (CBC)
- CPT code 76700: Ultrasound examination of an organ or structure
- CPT code 45378: Colonoscopy, diagnostic
Surgical Procedures
- CPT code 29881: Knee arthroscopy with meniscectomy
- CPT code 43235: Upper gastrointestinal endoscopy
- CPT code 47562: Laparoscopic cholecystectomy
Laboratory and Pathology
- CPT code 80053: Comprehensive metabolic panel
- CPT code 85027: Automated hemogram
Radiology
- CPT code 72148: Magnetic Resonance Imaging (MRI) of the lumbar spine
- CPT code 71045: Chest X-ray, single view
These are just a few examples of commonly used CPT medical codes across different medical specialties. It’s important to note that these codes are regularly updated and revised by the American Medical Association (AMA) to reflect advancements in medical procedures and technologies.
How do I find the appropriate CPT code for a specific medical procedure?
A critical step in medical coding and billing is determining the correct Current Procedural Terminology (CPT) code for a particular medical operation. The technique entails a thorough examination and comprehension of the operation carried out as well as the recommendations made by the American Medical Association (AMA). The following methods will assist you in locating the correct CPT code:
Identify the Procedure
Start off by stating exactly what surgery was carried out. This entails compiling all pertinent data, including the procedure’s goals, methods, and any unique situations or modifiers.
Consult CPT Code Resources
Look up CPT medical codes for the exact procedure using trustworthy sites. CPT code books, online databases, and coding tools are a few examples of this. These sources offer comprehensive descriptions of the codes, instructions, and any applicable rules or modifications.
Analyze Code Descriptions
Read the code explanations completely and contrast them with the actions you took. Pay close attention to the specifics listed in the code description and make sure they match the procedure’s nature, scope, and any special requirements.
Consider Additional Guidelines
In addition to the primary code explanations, CPT codes frequently come with particular instructions or suggestions. Review these recommendations carefully, and if necessary, incorporate them into your procedure. A patient’s age, anatomical location, or unique circumstances may all be taken into account in guidelines.
Verify Code Accuracy
Verify a prospective CPT medical code’s accuracy once you’ve located it. Make sure the code, taking into account any necessary specifics or modifications, corresponds to the executed operation. Check that the code adheres to any applicable coding standards or payer criteria, and that it reflects the utmost level of specificity possible.
Seek Expert Guidance if Needed
It is advised to seek professional advice if you run into difficulties or ambiguities while choosing a code. Consultants, coding specialists, or certified medical coders can offer helpful advice and guarantee appropriate code selection.
CPT Medical Codes Made Easy
The 3 categories of CPT medical codes might puzzle you. But after reading our detailed insider guide on CPT codes you will be able to better understand its classification and implementation. Step your journey towards increased revenue now!