How to use CPT Codes?

CPT is an expansive and important code set which is published and maintained by the American Medical Association (AMA).CPT and ICD code sets are important for medical billing and coding and every coder should be aware of it.

Healthcare providers offer various services such as surgeries, evaluations, and any other medical procedure to patients. These services are described with the help of CPT codes.

Generally, CPT codes are considered an integral part of and the billing process and these codes suggest insurance providers what procedures the healthcare provider would like to be reimbursed. Moreover, CPT codes work in tandem with ICD codes to get the whole view of the medical process for the payer.

CPT codes have various usages such as Government agencies that can use CPT codes to track the prevalence and value of certain procedures and hospitals may use CPT codes to evaluate the efficiency and abilities of individuals or divisions within their facility. Let’s look at how these codes look like and how they are organized.

Format of CPT codes

Each CPT code is five characters long and based on the categories (refers to the division of the code set.) it lies within, representation is numeric or alphanumeric.

Let’s look at the three categories of CPT codes:

Category I:

• A widely used and very common set of codes.
• It describes most of the procedures performed by healthcare providers in inpatient and outpatient offices and hospitals
• CPT codes are divided into six large sections based on which field of health care they directly pertain to which are evaluation and management, anesthesiology, surgery, radiology, pathology and laboratory, medicine. All these codes are arranged in numerical order:

• • Evaluation and Management: 99201 – 99499
  • Anesthesia: 00100 – 01999; 99100 – 99140
  • Surgery: 10021 – 69990
  • Radiology: 70010 – 79999
  • Pathology and Laboratory: 80047 – 89398
  • Medicine: 90281 – 99199; 99500 – 99607
• CPT codes also have several modifiers which are two-digit additions to the CPT code that describe certain important facets of the procedure. CPT modifiers are relatively straightforward but are very important for coding accurately.

Category II:

• This code set used primarily for performance management.
• These codes have four digits, followed by the character F. However, these codes are optional, but can provide important information that can be used in performance management and future patient care. For instance, Patient Safety 6015F: Patient receiving or eligible to receive foods, fluids, or medication by mouth
• There are not nearly as many Category II CPT Codes as there are in Category I, and in general, you will not use Category II frequently.

Category III:

• These code sets are temporary codes that describe emerging and experimental technologies, services, and procedures.
• Category III codes are archived in the CPT manual for five years. If at the end of five years the code has not been converted to Category I, then this procedure must be marked with a Category I “unspecified procedure” code.
• Category II codes are five characters long and are comprised of four digits and a terminal letter.

For example, the code for the fistulization of sclera for glaucoma, through the ciliary body is 0123T. In this case, the last letter of Category III codes is T.

After getting insights about the format, now we must aware of the committee responsible for maintaining CPT codes

CPT codes committee

CPT code set is maintained by The CPT Editorial Panel which is authorized by the AMA Board of Trustees to modify, revise, and update CPT codes, descriptors, rules, and guidelines.

This panel is composed of 17 members out of whom 11 are physicians nominated by the national medical specialty societies and approved by the AMA Board of Trustees.

Out of the 11, one member is reserved for expertise in performance measurement.

One physician is nominated from each of the following:

• Blue Cross and Blue Shield Association
• America’s Health Insurance Plans
• American Hospital Association
• CMS

After getting insights about the format and Committee responsible for CPT codes, now we must aware of some of the tips about using these CPT codes set.

Tips about using CPT code set

Selection of correct CPT Code

While selecting the correct CPT code, it must be verified by medical necessity based on insurance guidelines. Moreover, you can take the help of the professional edition of the CPT coding book supplied by the American Medical Association for selecting a code set. The payment will likely be denied by the insurance company if a procedure is not backed up by medical necessity.

Code Modifier

Generally, CPT codes demands for modifiers, or letters or numbers added to the code which gives the insurance company in-depth details. Modifiers consist of various aspects of medical coding, including anesthesia, X-ray, and surgery.

For instance, if an X-ray is performed on the right arm, then modifier RT is added to the CPT code. While modifier of -50 added to a CPT code means a procedure was done on both sides of the body. Claims denials can be prevented with the help of correct modifiers.

Guidance from payer

Coders should contact the insurance company if they are not sure about the CPT code used. Moreover, these payers offer details regarding medical billing, including the proper CPT and ICD-9 codes for the procedures performed. This guidance will ensure claims are processed promptly and the physician is reimbursed properly.

We are experts in the coding and billing for higher claims acceptance, faster reimbursements & more revenue. We can help you to pinpoint your financial opportunities to drive practice revenue while we fast-track your billing processes and collections.

FAQs:

Alex Peter

A Medical Coding Subject Matter Expert with over 16 years of experience in ICD-10 and CPT coding, clinical documentation, and revenue cycle management. Shares actionable insights to improve billing accuracy and support compliance-driven healthcare practices.