Friday, June 1, 2012

CPT Codes

CPT (Current Procedural Terminology) codes

CPT Codes are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical and diagnostic services. They are then used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer. Since everyone uses the same codes to mean the same thing, they ensure uniformity.

It should be noted, however, that uniformity in understanding what the service is, and the amount different practitioners get reimbursed will not necessarily be the same. For example, Doctor A may perform a physical check up (99396) and be reimbursed $100 by your insurance company. If you went to Doctor B, his reimbursement by your insurance company for that same checkup, Code 99396, might only be $90. (This is not true for Medicare patients. Medicare uses HCPCS codes instead.)

(There is another set of codes used by physicians and facilities, too. These are called ICD codes, like ICD-9 or ICD-10 codes. They do not relate directly to billing, so are described separately.)

CPT codes are developed, maintained and copyrighted by the AMA (American Medical Association.) As the practice of health care changes, new codes are developed for new services, current codes may be revised, and old, unused codes are discarded. Thousands of codes are in use, and they are updated annually. Development and maintenance of these codes is overseen by editorial boards at the AMA, and the publications of all the software, books and manuals needed by those who use them brings millions in income (*see note below) to the AMA each year.

The Current Procedural Terminology (CPT) code set is maintained by the American Medical Association through the CPT Editorial Panel. The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.

New editions are released each October. The current version is the CPT 2011. It is available in both a standard edition and a professional edition.

CPT coding is similar to ICD-9 and ICD-10 coding, except that it identifies the services rendered rather than the diagnosis on the claim.

CPT is currently identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Health Care Procedure Coding System.

Types of codes

There are three types of CPT codes: Category I, Category II, and Category III.

Category I:

Category I CPT Code(s). There are six main sections:
  • Codes for Evaluation and Management: 99201-99499
  • Codes for Anesthesia: 00100-01999; 99100-99150
  • Codes for Surgery: 10021-69990
  • Codes for Radiology: 70010-79999
  • Codes for Pathology & Laboratory: 80047-89398
  • Codes for Medicine: 90281-99199; 99500-99607

Category II:

Category II CPT Code(s) – Performance Measurement (optional) (Category II codes: 0001F-7025F)

Category III:

Category III CPT Code(s) – Emerging Technology (Category III codes: 0016T-0207T)

Examples of CPT Codes:
  •     99214 may be used for a physical
  •     90658 indicates a flu shot
  •     90716 may be used for chicken pox vaccine (varicella)
  •     12002 may be used to stitch up a one-inch cut on a patient's arm

If you use Medicare, you'll see CPT codes, but used a bit differently. Medicare uses HCPCS codes (Healthcare Common Procedure Coding System.)

Matching CPT Codes to the Services They Represent

As patients, our interest in these codes is usually related to our doctors' and insurance billings. Until recently it was difficult to find out what certain CPT codes meant without contacting your insurance company or doctor's office.

You won't find a freely-available comprehensive list of CPT codes, because the AMA controls their publication. Groups that have tried to make them available for free to the public have been cited for violations, fined by the AMA and have been forced to remove them from the Internet. Since the AMA developed and copyrights the system, it has a right to make sure access to these lists is paid for. It licenses CPT code lists to groups who wish to publish the codes to make them available to others. Those groups then charge a fee for access, too.

We patients don't have the large sums of money needed to subscribe to websites or purchase publications that list CPT codes. To make them more accessible to us, the AMA does provide on its website a means for looking up the individual CPT codes you might find on your doctor's bills or EOBs (estimates of benefits).