In the United States healthcare industry, coded designations allow healthcare providers and insurers to assign value to services. These “CPT codes” are helpful in determining the total cost of medical services provided. After a patient receives care, the healthcare provider sends CPT codes to the patient’s insurer to bill for services, making them an integral part of healthcare payment processing.
This system enables the United States healthcare system to standardize the coding for healthcare services. While prices vary depending on healthcare providers, the standardized inputs reduce confusion for providers, insurers, and patients. Because they play such an integral role in healthcare designations and costs, their accuracy is paramount. Many hospitals employ professional coders who assign codes for procedures and other medical services.
If you’re new to this methodology, you likely have many questions. In this guide, we’ll explore this system, its significance, and a host of other related topics on the subject matter. We’ll also take a closer look at some of the most prevalent CPT codes in the US healthcare system!
What is a CPT Code?
Current Procedural Terminology (CPT) codes are five-digit medical inputs describing the procedure or medical service provided by healthcare professionals, hospitals, laboratories, and other related entities [1]. For example, if a healthcare provider is billing an insurer for a routine check-up, they would likely list 99213 or 99214 as the input.
While many inputs consist of five digits, some inputs are four digits followed by a single letter. The American Medical Association (AMA) [2] regulates these inputs. They offer updated lists on a routine basis.
As the healthcare industry continuously evolves, the AMA releases new codes when new procedures and services become available to patients. Thus, healthcare coders must be constantly aware of updates.
What is Current Procedural Terminology?
Current Procedural Terminology (CPT) refers to the coded language communicated between healthcare providers, insurers, and patients.
What Are CPT Codes Used for?
The primary use is communicating services between healthcare providers and payers. Instead of healthcare bills detailing descriptive and subjective designations, these simplified inputs allow standardization across the industry.
While most providers use the same inputs for the same services, it’s essential to note this isn’t always the case. Some healthcare providers may define specific services differently.
Initial coding
Initial coding occurs when a healthcare provider lists the inputs relevant to a patient’s procedure or service. For example, if a patient comes for a check-up and requires various tests, healthcare providers record codes for the check-up and tests. This step is also referred to by the phrase “charge capture.”
This is relevant to paper and electronic filing. Many healthcare providers now have electronic coding systems enabling inputs according to the name of each procedure or service.
This initial coding allows healthcare providers to track services accurately. It is vital in the early stages of any treatment.
Verification and submission
After a healthcare appointment is complete, the healthcare provider’s staff reviews the coding on your file. At this stage, verification occurs to ensure all coding is correct.
Once verification is complete, the healthcare provider submits the input to the insurer or patient for payment. While most are submitted using digital platforms, some healthcare providers may still use fax or other submission methods.
Claim processing
Once submission occurs, it’s time to process the claim. If an insurance provider receives the input, they examine the bill and determine the total cost to pay to the healthcare provider. They also notify the insurance holder of how much they owe for the treatment if applicable.
At this point, the healthcare provider would then update their payment posting system.
Research
These inputs make it much easier to track healthcare data. Governments, insurers, and providers use coding data to assess patient needs and track future healthcare requirements. They provide a useful standardization tool for healthcare trend researchers.
By using simple inputs to describe services and procedures, healthcare researchers have easier access to uniform data.
What Are the Three Categories of CPT Codes?
The American Medical Association’s CPT code system is currently organized into three categories. Category I includes inputs for procedures, Category II for performance, and Category III for emerging services. While Category I is the most commonly used by providers and insurers, it’s good practice for those working in the medical industry to at least be familiar with Category II and Category III. Below further details each category.
Category I Codes: Procedures and contemporary medical practices
This category is most frequently used by healthcare providers and insurers. Here you will find CPT codes for standard treatments, procedures, and services. Within this category, there are six sections of inputs:
- Evaluation and Management, including consultations, hospital inpatient services, and preventative care.
- Anesthesia
- Surgery
- Radiology, including diagnostic radiology, diagnostic ultrasounds, and radiation oncology.
- Pathology and Laboratory, including drug testing, urinalysis, and transfusion medicine.
- Medicine, including immunization administration, dialysis, and acupuncture.
Category II Codes: Performance-based codes
These are CPT codes that don’t specify services or procedures. Instead, they track performance metrics, which can be useful for healthcare providers and researchers. These inputs are usually 4 digits followed by the letter F. There are currently 11 sections into which Category II codes are organized. They are:
- Composite measures
- Patient management
- Patient history
- Physical examination
- Diagnostic/screening processes or results
- Therapeutic, preventive or other interventions
- Follow-up or other outcomes
- Patient safety
- Structural measures
- Non-measure claims-based reporting
Unlike Category I, Category II CPT codes aren’t associated with a value, thus are billed as a $0.00 charge amount.
Category III Codes: Emerging technologies, services and procedures
These CPT codes cover experimental and emerging treatments. They’re typically temporary. These inputs are particularly useful in tracking data in the Food and Drug Administration’s approval process.
List of Commonly Used CPT Codes
There are thousands of CPT codes, which can be found on the Center for Medicare and Medicaid Service’s website [3]. While many inputs describe niche, uncommon services, more common ones see constant use. Here is a list of some common inputs and their meanings:
- 99214: Office visit
- 72050: X-ray exam of neck/spine
- 90658: Flu shot
- 72100: X-ray exam of the lower spine
- 77401: Radiation treatment delivery
Where Can I Find CPT Codes?
The American Medical Association (AMA) is the official resource, as they are the sole issuers of CPT codes. If you’re confused, it’s critical to use the AMA as a resource to avoid any conflicting information. It’s also critical to stay up to date. Not doing so leaves your medical practice without the ability to accurately bill for services or track services internally.
While you can find information on the AMA website, the organization also provides coding resources [4] to help medical practices stay updated with CPT codes. The organization has an app and other digital resources useful for medical practices and companies of any size.
The AMA also has a newsletter that provides constant updates for medical providers and insurers.
Examples of CPT Codes
If you’re searching for an example, it can be helpful to observe a small list of current CPT codes. While we already overviewed some inputs above, here are a few more examples:
- 73600: X-ray exam of ankle
- 73565: X-ray exam of knees
- 73590: X-ray exam of the lower leg
- 74150: CT abdomen w/o dye
- 86930: Frozen blood prep
- 74160: CT abdomen w/dye
- 97010: Hot or cold packs therapy
- 97012: Mechanical traction therapy
- 97016: Vasopneumatic device therapy
- 92597: Oral speech device eval
- 0230U: AR full sequence analysis
- 86927: Plasma fresh frozen
- 86931: Frozen blood thaw
- 92526: Oral function therapy
- 92607: Ex for speech device RX 1hr
As you can see above, some use five numerical digits. Others use four numerical digits and a single letter.
How to Use CPT Codes in Your Medical Practice
If you’re the owner or operator of a medical practice, it’s important to understand how to use CPT codes correctly. Because they help you charge patients for medical services and procedures, they’re a critical element in accepting payments in your practice.
While many medical providers focus on using the CPT system for billing insurance companies and payers, they also play a role in keeping your own internal records. When you use coding to describe services and procedures, you’re ensuring that treatments are accurately recorded. Keeping accurate records is essential in the healthcare industry. This can help you track services and procedures undergone by patients. Also, if a patient is confused about a bill or treatment, this coding allows you to clarify any errors.
Using qualitative record-keeping can spell disaster if there is any confusion. Using uniform inputs makes the process of auditing, analyzing, and clarifying much easier. Medical practices that want a deeper understanding of their business can use this coding for research and analysis. If you want to see what type of treatments patients receive most frequently or what type of follow-up treatments are common, they’re an excellent tool. You can also perform an analysis of your revenue cycle management. As these inputs are uniform, there very useful for creating datasets and visual data representations. This type of analysis would be much more difficult without standardized inputs.
As CPT codes are such an integral component in accepting payments in your medical practice, it may be worth hiring dedicated coding professionals for billing purposes. Many medical providers now use dedicated coders that handle insurance billing and CPT coding analysis. There are now many professionals with considerable experience in this niche.
Final Thoughts
After reading this guide, we hope we hope you have an understanding of CPT codes and their usefulness in the medical industry. Before introducing this system, the medical industry did not have an accurate way to unify reporting standards and insurance billing.
While the framework is not flawless, there is no doubt it adds value to the United States’ medical landscape. By standardizing inputs and allowing researchers to assess procedures, treatments, and services with better data, the medical industry can paint a more accurate landscape of healthcare needs. Also, insurers can receive much clearer information regarding treatments and services when using CPT coding.
If you’re a healthcare provider, ensuring your staff members have updated CPT protocols and codes is essential. Using the AMA as a resource can help you reduce errors and improve online invoicing standards.
Sources:
- Science Direct. Implementing a Successful Revenue Cycle in Your Pain Management Practice. Accessed January 11, 2022.
- American Medical Association. Ama-assn.org. Accessed January 11, 2022.
- Centers for Medicare and Medicaid Services. List of CPT/HCPCS Codes. Accessed January 11, 2022.
- American Medical Association. Need Coding Resources. Accessed January 11, 2021.
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