Understanding CPT Codes - idealmedhealth

What goes through your mind when you hear about CPT codes. Many must be asking what the meaning of CPT is.

We’ve compiled some information about the CPT code and all the knowledge that people wished to know about CPT codes.

What is CPT code

Firstly, CPT is an abbreviation that stands for Current Procedural Terminology. CPT code is a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies, and accreditation organizations.

CPT coding is the language of medicine today, offering doctors across the country a uniform process for coding medical services that streamlines reporting and increases accuracy and efficiency.

Evolution Of The CPT Code

The CPT was developed and published in 1966 by the AMA (American Medical Association).

The 1st edition helped encourage the use of standard terms and descriptors to document procedures in the medical record, helped communicate detailed information on procedures and services to agencies concerned with insurance claims, provided the basis for a computer-oriented system to evaluate operative protocols, and contributed basic information for actuarial and statistical objectives.

This 1st edition of CPT contained primarily surgical procedures, with limited sections on medicine, radiology, and laboratory procedures.

The 2nd edition was published in 1970 and presented an expanded system of terms and codes to designate diagnostic and therapeutic procedures in surgery, medicine, and specialties.

Furthermore, the 3rd and 4th were introduced and published in the mid-70s, 1970, and 1977 respectively.

The introduction of the 3rd and 4th editions kept pace with the rapidly changing medical environment.

In 1983 CPT was adopted as part of the Centers for Medicare & Medicaid Services (CMS), formerly Health Care Financing Administration’s (HCFA), Healthcare Common Procedure Coding System (HCPCS). With this adoption, CMS mandated the use of HCPCS to report services for the Medicare program.

Also, in 2000, the CPT code set was designated by the Department of Health and Human Services as the national coding standard for physician and other health care professional services and procedures under the Health Insurance Portability and Accountability Act (HIPAA).

See Also; How to become a medical coder

Furthermore, CPT is used extensively throughout the United States as the preferred system of coding and describing health care services.

Types Of CPT Codes

The CPT codes can be distinguished by the following three categories.

#1. Category 1 CPT code; this code describes distinct medical procedures or services furnished by QHPs(Qualified Healthcare Professionals) and is identified by a 5-digit numeric code [e.g., 29580: Unna boot].

New Category 1 CPT codes are released annually. Category 1 CPT codes are divided into six large sections based on which field of health care they directly pertain. The six sections of the CPT code are, in order;

Evaluation and Management
Anesthesiology
Surgery
Radiology
Pathology and Laboratory
Medicine

Here’s a quick look at the sections of Category 1 CPT codes, as arranged by their numerical range.

Evaluation and Management: 99201 – 99499
Anaesthesia: 00100 – 01999; 99100 – 99140
Surgery: 10021 – 69990
Radiology: 70010 – 79999
Pathology and Laboratory: 80047 – 89398
Medicine: 90281 – 99199; 99500 – 99607

#2. Category 2 CPT code; this code is referred to as the performance measurement code. These numeric alpha codes (e.g., 2029F: complete physical skin exam performed) are used to collect data related to the quality of care.

Category 2 codes are released three times a year in March, July, and November by the CPT Editorial Panel (panels responsible for maintaining the CPT code set). These codes never replace Category 1 or Category 3 codes, and instead, simply provide extra information.

#3. Category 3 CPT code; these codes are temporary tracking codes for new and emerging technologies to allow data collection and assessment of new services and procedures.

They are used to collect data in the FDA (Food and Drug Administration) approval process or to substantiate widespread usage of the new and emerging technology to justify the establishment of a permanent Category 1 CPT code.

Category 3 CPT codes are issued in a numeric alpha format (e.g., 0307T: near-infrared spectroscopy study for lower extremity wounds).

New Category 3 CPT codes are released biannually (January and July) with a 6-month delay before activation for implementation in the Medicare system.

Codes released on January 1st are effective till July 1st, and codes released on July 1st are effective till January 1st.

The codes usually remain active for five years from the date of implementation, if the code has not been accepted for placement in the Category 1 section of CPT.

Furthermore, before a new code is been proposed, it goes through the following steps;

The speciality society develops the initial proposal. Typically, the speciality society will be most familiar with trends shaping a specific speciality. As a result, the speciality society can represent important trends driven by technology, changing practices, etc.
The AMA Staff reviews the code proposal. This preparatory step confirms that the issue has not been previously addressed and that all of the documentation is in place.
The CPT Specialty Advisory Panel then reviews the code proposal. All are allowed to comment, and those comments are then shared with all participants in the process, but not with the general public.
The CPT Editorial Panel then reviews the code proposal at its regularly scheduled meeting. The group can approve the code, table the proposal, or reject the proposal.
Approved Category 1 codes are then submitted to the RUC(Royal Ulster Constabulary) for valuation.

The CPT editorial panel plays a huge role in the category 3 CPT code because there are criteria used in evaluating the category 3 code for emerging technology. Those criteria include;

A protocol for a study of procedures being performed.
Support from the specialities that would use the procedure.
Availability of U.S. peer-reviewed literature.
Descriptions of current U.S. trials outlining the efficacy of the procedure.

There are major information requirements for a new CPT code application which include the following;

A complete description of the procedure or service (e.g., describe in detail the skill and time involved. If a surgical procedure, include an operative report that describes the procedure in detail).
A clinical vignette describes the typical patient and work provided by the physician/practitioner.
The diagnosis of patients for whom this procedure/service would be performed.
A copy(s) of peer-reviewed articles published in U.S. journals indicating the safety and effectiveness of the procedure.
The frequency with which the procedure is performed and/or estimation of its projected performance.
A copy(s) of additional published literature, which further explains the request (e.g., practice parameters/guidelines or policy statements on a particular procedure/service).
Evidence of FDA approval of the drug or device used in the procedure/service if required.
The rationale why the existing codes are not adequate and can any existing codes be changed to include these new procedures without significantly affecting the extent of the service?

Uses of CPT codes

CPT can be used in the following ways;

CPT codes are used in conjunction with ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) or ICD- 10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) numerical diagnostic coding during the electronic medical billing process.

ICD-9-CM; is the official system of assigning codes to diagnoses and procedures associated with hospital utilisation in the United States. The ICD-9 was used to code and classify mortality data from death certificates until 1999 when the use of ICD-10 for mortality coding started.

The ICD-9-CM consists of:

A tabular list containing a numerical list of the disease code numbers in tabular form;
An alphabetical index to the disease entries; and
A classification system for surgical, diagnostic, and therapeutic procedures (alphabetic index and tabular list).

ICD-10-CM; is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States.

The ICD-10-CM code set will enhance the quality of data for;

Tracking public health conditions (complications, anatomical location)
Improved data for epidemiological research (severity of illness, co-morbidities)
Measuring outcomes and care provided to patients
Making clinical decisions
Identifying fraud and abuse
Designing payment systems/processing claims

ICD codes has two types of users;

#1. A primary user; primary user of ICD codes includes health care personnel, such as physicians and nurses, as well as medical coders, who assign ICD-9-CM codes to verbatim or abstracted diagnosis or procedure information and thus are originators of the ICD codes. ICD-9-CM codes are used for a variety of purposes, including statistics and billing and claims reimbursement.

#2. A secondary user; secondary user of ICD-9-CM codes is someone who uses already coded data from hospitals, health care providers, or health plans to conduct surveillance and/or research activities.

Public health is largely a secondary user of coded data.

CPT code is also used for administrative management purposes such as claims processing and developing guidelines for medical care review.
They are used by insurers to determine the amount of reimbursement a practitioner will receive under your health insurance coverage (and ultimately how much of the bill you will be left responsible for).
CPT code is used to diagnose medical billing errors