Before, we were talking about the Current Procedural Terminology (CPT).
This is an essential and expansive code set issued and maintained by the American Medical Association (AMA).
Together with ICD, it is one of the most significant code sets that medical coders should know.
All these codes are copyrighted by the AMA.
CPT codes determine the procedures used for tests, evaluations, surgeries, and other medical activities that healthcare providers perform on patients
This code set is extremely expanded and includes thousands of medical procedures.
CPT codes are a fundamental part of the billing process.
These codes demonstrate the insurance carrier what procedures provided by a healthcare professional should be compensated for.
Therefore, CPT codes are closely connected with the ICD codes to create a comprehensive image of the medical process for the payer.
“This patient had these (as represented by the ICD code) symptoms, and we carried out these (as per the CPT code) procedures”.
Similar to ICD codes, CPT codes are used to track vital health data and evaluate performance and efficiency.
CPT codes are used by government agencies to track the value and prevalence of particular procedures.
Hospitals use these codes to assess the abilities and efficiency of individuals or teams working in their facility.
Let’s explore these codes closer, how they are organized, and look like.
Each CPT code contains five characters and can be numeric or alphanumeric.
This depends on the category of the CPT code.
It shouldn’t be confused with the ICD category.
In ICD codes, a category in the code refers to the first three characters, which describe the disease or injury which a healthcare provider documented.
In the CPT codes, “Category” refers to the code set division.
These codes are divided into three Categories.
The most common and frequently used set of codes in the CPT is Category I.
It includes the majority of procedures that healthcare providers perform in outpatient and inpatient hospitals and offices.
Category II includes additional training codes that are mostly used for performance management.
The codes in Category III are temporary and describe experimental and emerging technologies, procedures, and services.
Noteworthy, CPT codes contain five digits, but they aren’t 99,000+ codes.
These codes are made for revision and flexibility, and often, there’s a lot of “space” between codes.
Contrary to ICD, in the CPT code, every number does not stand for a particular technology or procedure.
Let’s explore all three categories closer.
Most of the time, medical coders work with Category I of the CPT codes.
To make it simpler, when describing the code set, we will refer to the CPT codebook.
This book is an essential tool for each medical coder, which AMA and the CPT Editorial Board update every year.
Below, you will find the basic format, layout, and instructions provided in the CPT codebook.
Similar to the ICD codes with their division into chapters based on the type of illness or injury, Category I in CPT codes is divided into six large parts by the healthcare field they directly refer to.
The six parts in the CPT codebook, in their order, include:
- Evaluation and Management.
- Pathology and Laboratory.
Mostly, CPT codes are grouped numerically.
For example, the codes for surgery are 10021 through 69990.
The CPT book lists these codes mainly in numerical order, except for those that refer to Evaluation and Management (E&M).
E&M codes are collected in the front of the book for easier access.
These codes are usually used in physicians’ offices to report a number of their services.
For example, the E&M codes include code 99214 for a general checkup.
Some codes are listed out of numerical sequence but close to similar procedures.
It might appear a bit confusing, but since these codes are collected near similar procedures, there’s no need to delete and resequence codes, so it is sort of necessary.
Here are the sections of Category I of the CPT codes, arranged by their numerical range:
- 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.
Each of these fields contains a subfield corresponding to how a topic is applied in a specific healthcare field.
For example, the largest part, Surgery, is organized by the human body parts that surgery will be performed on.
Similarly, the Radiology section contains parts organized by diagnostic ultrasound, joint and bone studies, radiation oncology, etc.
When it comes to the use of these fields, each of them has specific guidelines.
For instance, the Surgery section includes a guideline for the report of extra materials used (e.g., drugs or sterile trays).
It also has a guideline for the reporting of follow-up care of the surgical procedures.
Similar to ICD codes, a lot of CPT codes are collected in paragraphs.
If a procedure is paragraphed below another code, the arranged procedure is an essential variation of the above procedure.
It would replace the first code.
Take a look at the example.
The “management of liver hemorrhage; simple suture of liver wound or injury” has the code 47350.
This is a surgical procedure, which can be found in the surgery/digestive system section of the book.
It’s useful to look at this code in two parts.
The first part comes before the semicolon and is a general procedure.
In this case, it’s “liver management.”
The part after the semicolon is supplemental, specific information.
In this code, we can read it as “liver management, with a simple suture of liver wound or injury.”
However, if a doctor performed a more complex procedure, the 47350 code won’t be applicable anymore.
In the CPT manual, the code 47360 is found below 47350.
The 47360 code means “complex suture of liver wound or injury, with or without hepatic artery ligation.”
This is meant to replace the phrase after the semicolon in the 47350 code.
Therefore, code 47360 can be read as “liver management, with complex suture of liver wound or injury, with or without hepatic artery ligation.”
There are also modifiers in the CPT codes.
They are two-digit additions to the CPT code, describing particular essential facets of the procedure.
For instance, if the procedure is bilateral or one of the multiple procedures performed simultaneously.
These modifiers are relatively straight-lined but are essential for coding accurately.
Similar to ICD codes, CPT codes may include additional instructions below the code.
They are written in parentheses below the code, and tell the coder that in some specific situations, another code would be more appropriate than the given one.
For now, just remember that the set of CPT codes has instructions that provide information to medical coders on how to code the procedure best.
Keep in mind, that procedures should be coded to the highest level of precision.
If the procedure was miscoded, it can make a difference between a rejected or accepted claim.
The CPT code is designed to instruct coders when multiple codes should be used when to use add-on codes, and which are “modifier exempt.”
This is a vast amount of information about Category I of CPT codes, so let’s briefly review it.
Codes in this category are numeric and are five digits long.
The codes are divided into six sections, which include Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine.
Each of them has sub-sections, standing for the type of procedure, or the body part to which the procedure relates.
Except for the Evaluation and Management section, they are arranged in numerical order.
E.g., the Anesthesia codes come before (are lower) than Pathology and Laboratory codes.
Every section comes with guidelines on how to use the codes in them.
Specific codes come with related procedures that are paragraphed below them.
They are the essential variations for the code above and indicate different methods, approaches, or outcomes of the same procedure.
For example, 62000 is the code for the elevation of a simple, extradural depressed skull.
Code 62005 is for the elevation of a compound or comminuted, extradural depressed skull fracture.
They also include some essential CPT Modifiers that give additional information about the procedure.
Some codes come with instructions below them.
They are provided in parentheses below the code and instruct the coders that they may have another, more specific, code to use.
The codes in this category are alphanumeric and contain five characters.
They provide additional information to the codes from Category I.
They are formatted in four digits followed by the character F.
These codes can contain important information for management and future patient care, but they are optional.
For example, if during a routine checkup, a doctor recorded Body Mass Index (BMI) of the patient, the Category II code 3008F would be used.
It means “Body Mass Index (BMI), documented.”
These codes aren’t a substitute for codes from Category I or III.
They simply give more information.
The codes are divided into numerical fields.
Each field corresponds with a particular element of patient care.
- These codes indicate the number of procedures performed together with the main procedure.
- Example: 0001F: heart failure assessed includes:
- Blood pressure measured.
- Weight recorded.
- Clinical symptoms of volume overload assessed.
- Level of activity assessed.
- Example: 0001F: heart failure assessed includes:
- Clinical signs of volume overload assessed.
- Describe measures for select elements of symptom review or patient history.
- Example: 1030F: Pneumococcus immunization status assessed.
Diagnostic/Screening Processes or Results:
- Includes results of tests, including clinical laboratory tests and radiological procedures.
- Example: 3006F: Chest X-ray documented and reviewed.
- Includes patient care provided for specific clinical purposes like pre- and postnatal care.
- Example: 0503F: Postpartum care visit.
- Example: 2014F: Mental status assessed
Follow-up or Other Outcomes:
- These codes specify the communication and review of test results to a patient, patient functional status, patient satisfaction, and patient morbidity or mortality.
- Example: 5005F: patient counseled on self-examination for new or changing moles.
Therapeutic, Preventive, or Other Interventions:
- Describes procedural, pharmacologic, or behavioral therapies.
- Example: 4037F: influenza immunization ordered or administered.
- Codes in this short section describe the setting of delivered care and cover the skills of the healthcare provider.
- Example: 7025F: patient information entered into a reminder system with a target due date for the next mammogram.
- Includes codes that describe patient safety precautions.
- Example: 6015F: Patient receiving or eligible to receive foods, fluids, or medication by mouth.
Category II doesn’t include nearly as many codes as Category I, and they are not as much in use either.
It is still an essential element of the CPT code set, which you should be familiar with if you’re going for a career in the field.
Category III of CPT codes comprises temporary codes, representing experimental or emergent procedures, services, and technology.
Sometimes, a newer procedure may not have a code in Category I.
Category I has some unlisted procedures, but if the service, procedure, or technology is from Category III, this is what you should use.
These codes provide more specificity in coding and help government agencies and healthcare facilities track the efficiency of emergent and new medical techniques.
Basically, Category III codes are those that may become Category I or don’t match Category I.
Codes in Category I should be approved by the CPT Editorial Panel.
This Panel requires the procedures or services to be performed in a number of facilities in various locations.
It also states that the procedures are approved by the FDA.
With the nature of emerging medical procedures and technology, experimental procedures can’t always meet these criteria and become a code of Category I.
Despite a code of Category III becoming or not becoming a code of Category I, all codes in Category III are archived in the CPT manual for five years.
If during these five years, the code did not become a Category I code, it should be marked as Category I “unspecified procedure” code.
All codes in Category III have the expiration of the validity listed below the code.
This can be seen as an expiration date of the code.
Similar to Category II, these codes contain five characters and have four digits and a terminal letter.
The last letter in these codes is T.
For example, 0123T is the code for the fistulization of sclera for glaucoma, through the ciliary body.