A Guide to CPT Codes and How to Use Them

An overview of CPT coding

Use our CPT code guide for an overview of the standardized coding system, which is essential for health care professionals and medical coders to document medical services and procedures accurately. Current procedural terminology (CPT) codes, maintained by the American Medical Association (AMA) through the CPT Editorial Panel, include Category I CPT codes, Category II CPT codes, and Category III CPT codes, each serving distinct purposes in identifying medical services and facilitating claims processing.

This widely accepted medical nomenclature is integral to healthcare, supporting the billing process, claims review, and quality reporting for procedures furnished by healthcare professionals. The CPT coding system ensures consistency in clinical practice and patient care documentation, whether coding medical services for private insurers, Medicaid services, or Medicare billing.

Importance of CPT codes

The CPT code set serves as a common language for healthcare professionals and insurance companies. This ensures everyone is on the same page regarding treatments and services, ensuring accuracy in billing, reimbursement, and quality of care. 

Using CPT codes correctly can help improve patient outcomes by allowing medical professionals to document treatments and procedures accurately. Additionally, accurate CPT coding ensures that patients receive the best healthcare possible. 

Insurance companies also use CPT codes to determine how much they will pay providers for particular procedures. For instance, using CPT codes for family therapy billing is crucial in the medical process. It ensures that the therapist is paid correctly and that family members adequately compensate for their time.

Three categories of CPT codes

There are three categories of CPT codes, and they serve different purposes.

Category I

Category I codes describe medical procedures and services, including surgeries, tests, consultations, and treatments. This category is divided into sections based on the healthcare field they apply to. These sections include:

• Evaluation and management
• Anesthesiology
• Surgery
• Radiology
• Pathology and laboratory
• Medicine services and procedures

Each section consists of a range of five-digit numerical codes assigned to specific services. Apart from CPT codes for Evaluation and Management, the codes are listed in numerical order:

• Evaluation and management: 99202 – 99499
• Anesthesia: 00100 – 01999
• Surgery: 10004 – 69990
• Radiology: 70010 – 79999
• Pathology and laboratory: 80047 – 89398
• Medicine services and procedures: 90281 – 99607 

There are also other specific CPT codes. For example, some of the CPT codes for counseling are 90832 and 90837, while CPT codes for occupational therapy evaluation are 97165, 97166, and 97167.

Category II

Category II codes are used to track performance measurements and other activities. These codes are used with Category I codes to provide additional information about how the service was provided.

For example, a Category II code can indicate whether an experienced professional or a trainee provided a particular treatment or procedure. These codes do not directly affect reimbursement but are rather used to report quality measures and performance improvement activities.

These CPT codes can't replace Category I or III codes, but they provide extra information. They typically contain five characters:

• Composite measures: 0001F – 0015F
• Patient management: 0500F – 0584F
• Patient history: 1000F – 1505F
• Diagnostic/screening processes or results: 3006F – 3776F
• Therapeutic, preventive, or other interventions: 4000F – 4563F
• Follow-up or other outcomes: 5005F – 5250F
• Patient safety: 6005F – 6150F
• Structural: 7010F – 7025F

Category III

Category III CPT codes report emerging medical services and technologies that don't fit the existing categories. They are used to accurately track new developments in healthcare delivery, such as robotic surgery or teledermatology.

These codes are designed to provide more specificity in coding, and they also help facilities and organizations track the effectiveness of new, emergent medical techniques.

Category III codes may eventually be incorporated into Category I codes if they become widely used or if greater specificity is needed.

How are CPT codes used?

Medical coders use CPT codes when filing claims to insurance companies and government agencies. They allow healthcare providers to get paid for their services and help insurance companies accurately track those services.

Do note that there's a difference between CPT codes and HCPS codes. CPT codes are used to describe medical procedures and services. HCPCS codes, on the other hand, are used to identify products, supplies, and services not covered by CPT codes.

 Here's how to use CPT codes:

Initial coding

For initial coding, CPT codes should be selected according to the type of service or procedure provided to a patient. Selecting the correct codes is crucial because it affects the accuracy of filing claims. The reimbursement amount from insurance companies can vary depending on the code chosen.

Verification and submission

Once the codes for service have been chosen, they should be verified against the official CPT coding manual, which stands as a guide for CPT codes. This helps avoid any delays in processing claims. After verifying the codes, you can submit them to insurance companies or government agencies for reimbursement.

For example, you can use CPT codes for psychological testing and evaluation when submitting Medicare claims for a neuropsychological assessment. CPT codes provide the relevant information needed to track those services and ensure proper payment for the services provided.

Claim processing

Once the codes have been submitted, the insurance company or government agency will review them to ensure they're accurate and used correctly.  The CPT codes are then used to generate an explanation of benefits (EOB) that details how much money the patient or provider will receive from the insurance company.

Research

CPT codes help researchers track patient outcomes and the effectiveness of treatments. 

The codes can also be used to compare services across different healthcare providers, allowing for a better understanding of trends in medical practices. This helps researchers determine which treatments are most effective and how they should be used in practice.

Conclusion

CPT codes are essential tools in the healthcare industry since they help track and reimburse medical services. They can also be used for research and to compare treatments across different providers.

By understanding the different types of codes and how to use CPT, healthcare providers can ensure accuracy when filing claims and maximize the reimbursement they receive. With the right tools and resources, medical coders can easily use CPT codes to ensure accuracy in tracking and filing claims. This will help create a more efficient and cost-effective healthcare system.