In simple terms, the CPT code is a standardized system of 5-digit alphanumeric codes used in the U.S. for describing and coding medical, diagnostic, and surgical services. Think of CPT codes as a universal language for describing medical procedures and services. They are like unique identifiers that tell everyone, from doctors to insurance companies, exactly what was done during a patient's visit.
Since every medical procedure – from a simple health check-up to a surgical event – has a corresponding CPT code, it makes it easier for health professionals to record patient data without any manual errors and create accurate reports for healthcare providers, government agencies, and insurers. Moreover, it helps ensure correct billing and reimbursement claims.
History of CPT codes
The development of CPT codes began in the early ‘60s as a way to standardize medical terminology and reporting. The first set of codes was published in 1966. While the initial code set was used only for procedural terminology, they have now expanded to include all healthcare services for the ease of billing and analytics.
In 1983, the Centers for Medicare and Medicaid Services (CMS) adopted CPT as part of the Healthcare Common Procedure Coding System (HCPCS). This adoption marked the beginning of the use of CPT codes across all medical billing and documentation in the United States, not just within Medicare.
The CPT codes are currently divided into 4 categories:
- Category I: Codes for procedures and contemporary medical practices that are widely performed. Common examples include 99213 (Office or another outpatient visit for the evaluation and management of an established patient), 90716 (Chickenpox vaccine, live, for subcutaneous use), 33533 (Coronary artery bypass, using venous graft(s) and arterial graft(s); three coronary arterial grafts).
- Category II: Optional performance management codes to track the execution of services in a standard measurement. Common examples include 3006F: Body mass index (BMI) documented. 4004F: Screening for osteoporosis is documented, indicating that a risk assessment was performed. 5010F: Tobacco use assessed and cessation intervention if the patient is a tobacco user.
- Category III: Temporary codes for emerging technologies, services, and procedures. Common examples include 0507T: Oncofertility preservation and sperm banking. 0544T: Insertion or replacement of neurostimulator system for treatment of central sleep apnea.
- PLA codes: PLA codes, or Proprietary Laboratory Analyses codes, are a specific category of CPT codes designed to represent laboratory tests that are unique or proprietary to a particular lab or manufacturer. Unlike traditional CPT codes, which are reviewed and approved by the American Medical Association (AMA), PLA codes are approved directly by the AMA CPT Editorial Panel.
Importance of CPT codes
CPT codes are like a secret handshake between healthcare providers. It is like saying, “This patient was given a flu shot,” but in a coded language that only healthcare providers will understand.
CPT codes go beyond labels. They provide specific details about every procedure, location, technique used, and any additional services performed. These details help in:
- Maintaining accurate bills for patients and hospitals and making reimbursements easier. Insurance agencies use these codes to determine the feasibility of reimbursement.
- Creating a uniform and consistent language in which medical procedures are described. Patients cannot always be relied upon to explain the medical technicalities; hence, the code is needed.
- Creating a database for medical research and data analysis. By tracking the frequency of different procedures, healthcare providers and researchers can identify trends, assess the effectiveness of treatments, and improve patient care.
Limitations of CPT codes
As we have seen above, CPT codes are very helpful in maintaining the accuracy of billing and record-keeping. However, the sheer volume of codes and frequent updates can make it challenging for healthcare providers to stay current.
Some codes may need to fully capture the nuances of complex medical procedures, leading to potential inaccuracies in billing and documentation. Codes may also be interpreted differently across regions or institutions despite standardization, affecting consistency.
While documentation is helpful in many ways, sometimes extensive documentation requirements can also add to the workload of healthcare providers and administrative staff.
The different categories of CPT codes
Category I (5-digit numeric codes)
The Category I codes are standardized codes for common medical procedures and are divided into 6 sections.
- Evaluation and Management (E/M) (99202–99499): This section includes codes for day-to-day patient encounters, such as office visits, hospital visits, consultations, and preventive care services.
- Anesthesia (00100–01999): These codes are used to describe the use of anesthesia during surgical, diagnostic, or therapeutic procedures. They cover anesthesia services for all parts of the body and include specifics about the procedure, the technology used, and the type of anesthesia administered.
- Surgery (10004–69990): Since there are multiple kinds of surgeries possible, this section is further subdivided to explain the exact surgical procedure. The subsections are designed by the body system, such as integumentary, musculoskeletal, respiratory, cardiovascular, and more. Each subsection includes codes for operations and surgical procedures specific to that part of the body.
- Radiology (70010–79999): These codes provide information about diagnostic imaging and, in some cases, therapeutic procedures, including X-rays, MRIs, ultrasound, CT scans, and nuclear medicine.
- Pathology and Laboratory (80047–89398): Codes in this section are used for laboratory and pathology services, such as blood tests, biopsies, and other diagnostic laboratory procedures. These include a vast spectrum of tests ranging from basic blood analyses to more complex genetic testing.
- Medicine (90281–99199, 99500-99607): This diverse section includes codes for a wide range of services such as physical therapy, psychiatric services, immunizations, allergen immunotherapy, and more. It covers medical procedures that do not fall strictly into the other categories, including some specialities and mixed services.
Example Codes:
99213: Established patient office visit, 15 minutes.
71020: Chest X-ray, two views.
93000: Electrocardiogram (ECG) with interpretation.
Category II
Category II CPT codes are supplementary codes used to track and report information about medical services and procedures that insurance companies do not reimburse. These codes are not used for billing purposes but are valuable for tracking the performance of healthcare providers and facilities and for monitoring public health issues and trends.
Note: While Category I codes are used for billing and have a specific dollar value assigned, the Category II codes do not have any dollar value. They are further sub-divided into:
- Composite codes (0001F–0015F): These codes are used to track the performance of multiple elements of a composite process. For instance, they might combine various aspects of diabetes care into a single measure to assess overall management effectiveness.
- Patient management (0500F–0584F): This section includes codes related to the duration and type of services provided, such as time spent in intensive care or under observation.
- Patient history (1000F–1505F): Codes under this section deal with the documentation of patient history elements, which are important for evaluating quality of care, such as noting tobacco use or family medical histories.
- Physical examination (2000F–2060F): This includes codes that report findings from physical exams that are relevant to preventive health measures and ongoing patient care assessments.
- Diagnostic/Screening processes or results (3006F–3776F): These codes are used to document procedures and the results of diagnostic or screening tests, such as blood pressure measurements or cancer screenings.
- Therapeutic, preventive, or other interventions (4000F–4563F): This section covers codes related to specific therapeutic procedures or preventive measures, like vaccinations or the administration of certain medications.
- Follow-up or other outcomes (5005F–5250F): Includes codes that track the outcomes of care or necessary follow-up actions, such as readmissions to the hospital or follow-up visits after treatment.
- Patient safety (6005F–6150F): This section is dedicated to tracking issues related to patient safety, including complications or other safety concerns arising during care.
- Structural measures (7010F–7025F): This section includes codes that relate to the structure of the healthcare delivery environment itself, which can affect patient outcomes. These might consist of measures related to electronic health record systems, staff qualifications, or facility accreditation.
- Non-measure code listing (9001F–9007F): These are not specific measures but are codes used to facilitate data collection or to denote particular conditions in the healthcare process, such as administrative processes or other aspects not covered by the more outcome-focused measures.
Category III
Category III CPT codes represent temporary codes used for emerging technologies, services, and procedures. Again, these codes are not used for billing. However, they are helpful for data collection and assessment of new services and technologies that may still need to be widely adopted or proven for effectiveness.
Category III codes help in tracking the utilization of these new technologies, which can support further research and evaluation for possible transition to permanent codes if said technologies become standard practice.
Moreover, as mentioned above, the CPT code manual also includes the PLA codes for identifying and reporting laboratory tests.
How are CPT codes developed and approved
Development and approval of these codes follows a three-step process:
- The development of new codes is initiated by healthcare professionals, societies, or other stakeholders who submit proposals for new codes or modifications.
- An editorial panel convened by the American Medical Association (AMA) reviews all proposals, ensuring that each code meets specific criteria for clarity, accuracy, and necessity.
- Once reviewed, the panel votes on codes. Approved codes are then published annually in the CPT code set – usually on January 1 of each year — with updates reflecting new medical technologies and procedures. These updates can include new codes, revisions to existing codes, and deletions of obsolete codes.
Maintenance of codes
The AMA remains the primary custodian of CPT codes, overseeing their development, revision, and dissemination. They manage a CPT Editorial Panel composed of representatives from various sectors of the healthcare industry, including physicians, hospitals, and health insurers.
This panel is responsible for the continuous evaluation of new procedures and technologies for inclusion as new codes and for revising existing codes to reflect changes in medical practice or technology. The panel meets three times a year to discuss changes and updates.
The process of updating CPT codes is transparent and involves input from the healthcare community. The AMA solicits feedback from practitioners, medical speciality groups, and the wider health industry to ensure the codes accurately reflect current practices and are useful for their intended purpose of billing and analysis.
Fortunately, AI-powered medical coders like Amy from CombineHealth are here to help. These AI medical coders analyze medical records, including doctor notes, test descriptions, medical history, etc., and automatically assign the appropriate CPT codes based on the documented diagnoses and procedures. This reduces human error and increases coding accuracy. Like human coders, Amy also recognises gaps in medical documentation, promptly querying the providers to give additional context required to determine the most appropriate ICD or CPT code.
FAQs
1. What are CPT codes used for?
CPT codes are used to describe medical procedures and services for billing, coding, and research purposes. They provide a standardized language that healthcare providers, insurance companies, and researchers can understand.
2. Who develops CPT codes?
The American Medical Association (AMA) is responsible for developing and maintaining CPT codes. A committee of medical experts reviews and updates the codes annually.
3. How do I find the correct CPT code for a specific procedure?
The AMA publishes a CPT codebook that provides detailed descriptions and guidelines for each code. You can also use online CPT code lookup tools or consult with a medical coding specialist.
4. Can I use a CPT code for a procedure that is not listed in the codebook?
If you cannot find a suitable CPT code for a procedure, you may need to submit a request for a new code to the AMA. This process involves providing detailed documentation and justification for the latest code.
5. Can I use CPT codes for billing services that are not covered by insurance?
Yes, you can use CPT codes to bill for self-pay services or services that are not covered by insurance. However, it is important to consult with your state's regulations regarding out-of-pocket billing.
