A CPT code is a five character code from the Current Procedural Terminology code set that describes a medical, surgical, or diagnostic service a provider performed. The American Medical Association (AMA) publishes this code set. Insurers use CPT codes to process claims and pay providers. Therefore, accurate CPT coding is a core skill for every medical coder. This guide explains what CPT codes mean and how the code set organizes them. It also shows how to look them up and the step by step process for coding with CPT.
What Is a CPT Code?
CPT stands for Current Procedural Terminology. In addition, the AMA publishes and updates the CPT code set every year, with new, revised, and deleted codes taking effect January 1. In the United States, HIPAA names CPT as the standard code set for reporting physician and outpatient procedures and services. As a result, commercial payers, Medicare, and Medicaid all use it. Coders often call the current version CPT 4, its fourth edition.
A CPT code tells the payer what the provider did. In contrast, an ICD-10-CM code tells the payer why the provider did it. Therefore, every claim pairs the two so medical necessity supports the service. Supplies, drugs, and services not covered by CPT are reported with HCPCS Level II codes and modifiers.
CPT Code Format: The Three Categories
- Category I: five digit numeric codes for the procedures and services providers report most often. CPT groups them into six sections: Evaluation and Management (99202 to 99499), Anesthesia (00100 to 01999), Surgery (10004 to 69990), Radiology (70010 to 79999), Pathology and Laboratory (80047 to 89398), and Medicine (90281 to 99199 and 99500 to 99607).
- Category II: four digits followed by the letter F, such as 1000F. These optional tracking codes report quality and performance measures.
- Category III: four digits followed by the letter T, such as 0042T. These temporary codes report emerging technology, services, and procedures.
Common CPT Code Examples
- 99213: office or other outpatient visit for an established patient, low level medical decision making
- 97140: manual therapy techniques, each 15 minutes, a common physical therapy procedure code
- 36415: collection of venous blood by venipuncture
- 80053: comprehensive metabolic panel
- 71046: chest x ray, two views
How to Look Up CPT Codes
Always code from a current year CPT manual or an AMA licensed tool, never from a free list of CPT codes, because codes and descriptors change every January. Reliable options include:
- The printed CPT code book (Professional Edition), the same book you bring to the CPC exam
- Encoder software such as AAPC Codify, which most employers use
- The CMS Physician Fee Schedule Look Up Tool for payment information
Start in the CPT index with the main term for the procedure, then verify the code in the tabular section and read the section guidelines and parenthetical notes before you assign it. Our online medical coding classes teach you to navigate the CPT manual the way the CPC exam requires.
Guidelines for Coding with CPT: Step-by-Step Approach
Current Procedural Terminology (CPT) codes are essential for reporting medical services and procedures in a standardized manner. Accurate coding using CPT guidelines also ensures proper billing and reimbursement. Here’s a step-by-step guide to help you navigate the coding process.
Step 1: Understand the Structure of CPT Codes
Overall, CPT divides its codes into three categories:
- Category I: Codes for procedures and services (e.g., surgery, radiology, evaluation and management).
- Category II: Supplementary tracking codes for performance measures (optional).
- Finally, Category III covers temporary codes for emerging technologies, services, and procedures.
Step 2: Gather Necessary Information
Before coding, collect all relevant information from the patient encounter, including:
- Patient history and medical records
- Details of the procedure or service performed
- Documentation supporting medical necessity
Step 3: Identify the Service or Procedure
To begin with, determine the specific service or procedure the provider performed. This includes:
- Evaluation and Management (E/M): Identify the type of visit (new vs. established patient) and the level of service based on history, examination, and medical decision-making.
- Surgical Procedures: Identify the specific surgical procedure and any modifiers that may apply.
- Other Services: Include diagnostic tests, radiology, or therapy services.
Step 4: Locate the Correct CPT Code
- Use the CPT Index:
- Start with the CPT index, because it organizes entries by service type and keywords.
- Then, look up terms related to the service or procedure to find the corresponding code range.
- Review the Main Text:
- After finding a code in the index, refer to the main text for descriptions, guidelines, and any specific instructions associated with the code.
- Also, pay attention to notes about code combinations, modifiers, and exclusions.
Step 5: Select the Appropriate Code
- Choose the Most Specific Code: Then, select the code that most accurately describes the service provided.
- Modifiers: Determine if any modifiers apply (e.g., 25 for a significant, separately identifiable E/M service). In addition, modifiers can provide additional context to the service billed.
Step 6: Verify Coding Guidelines
Before finalizing the code selection, review the following:
- CPT Guidelines: Each section of the CPT manual has guidelines that you must follow for proper coding.
- Payer-Specific Guidelines: Check for any specific requirements from the insurance payer, because they may have additional coding rules.
Step 7: Document Thoroughly
Accurate documentation is crucial because it substantiates the codes you select. Ensure that:
- All relevant information appears in the patient’s medical record.
- The documentation supports the level of service billed, particularly for E/M codes.
- The record also notes any relevant tests, assessments, or follow-up plans.
Step 8: Review and Submit Claims
- Double-Check Codes: Before submission, review all selected codes for accuracy and completeness.
- Electronic Submission: Utilize electronic claims submission systems, because they can help minimize errors and streamline the process.
In conclusion, mastering the steps to code using CPT is essential for healthcare professionals who work in billing and coding. By following these guidelines, you can enhance coding accuracy, improve claims processing, and ultimately ensure appropriate reimbursement for services rendered. In addition, regular training and updates on coding changes will further support effective coding practices.
CPT Code FAQs
What does CPT stand for in medical coding?
CPT stands for Current Procedural Terminology, the code set the AMA publishes to describe medical, surgical, and diagnostic services.
Which organization publishes the CPT coding system?
The American Medical Association (AMA) owns, publishes, and updates CPT every year.
What is a CPT code used for in insurance?
Providers report CPT codes on claims to tell insurers which services they performed. Payers then use them, with the matching ICD-10-CM diagnosis codes, to decide coverage and payment.
How many categories of CPT codes are there?
Three. Category I covers common procedures and services, Category II covers performance tracking, and Category III covers emerging technology.
Are CPT codes universal?
CPT is the standard procedure code set across the United States. Medicare, Medicaid, and commercial insurers all use it. However, other countries use their own procedure classifications.
What is evaluation and management in medical coding?
Evaluation and Management (E/M) codes, 99202 to 99499, report office visits, hospital visits, and other patient encounters. Coders choose levels by medical decision making or total time.
How can I practice CPT coding?
For example, work through medical coding test questions and real case scenarios. Our CPC exam guide explains what the exam covers and how to prepare.