When do you use cpt codes

For private pay practices, the correct CPT code must be included on the superbill or insurance companies will deny the claim. The system was first developed in by the American Medical Association and continues to be administered by them.

CPT Codes are different than ICD codes, which identify diagnoses of medical conditions, not what treatment was provided. These codes area also necessary for billing insurance companies as they explain why the treatment described by the CPT code was provided. You can learn more in our guide to ICD codes. CPT codes are available to providers in several ways. The American Academy of Professional Coders AAPC provides a subscription resource that provides detailed explanations of CPT codes and a code generator tool that matches codes to specific medical treatments.

Temporary codes describing new services and procedures can remain in Category III for up to five years.

If the services and procedures they represent meet Category I criteria—which includes FDA approval, evidence that many providers perform the procedures, and evidence that the procedures have proven effective—they will be reassigned Category I codes.

Conversely, Category III codes can be eliminated if providers do not use them. First, as you might imagine, procedural coding necessitates a solid grasp of anatomy and medical terminology. One procedure might have numerous variations, differing only slightly, and selecting the right code will require an ability to comprehend the clinical documentation and code description—to understand what a given procedure is, how the physician performed it, and which code descriptor captures the highest specificity of the procedure performed.

They are not limited by the specialty in which they practice. For example, X-ray codes are listed under radiology, but a primary care coder will be required to assign an appropriate X-ray code if the primary care physician interprets an X-ray.

This is the best way to ensure coding accuracy and optimal reimbursement for your employer. A modifier consists of two numbers, two letters, or a number and a letter.

For example, some modifiers show that a procedure was performed on the right side of the body, versus the left side or both sides. Other modifiers indicate that a physician took extra time and effort to perform a service or procedure.

As you might imagine, this code set is extremely large, and includes the codes for thousands upon thousands of medical procedures. CPT codes are an integral part of the billing process. CPT codes tell the insurance payer what procedures the healthcare provider would like to be reimbursed for.

Government agencies can use CPT codes to track the prevalence and value of certain procedures, and hospitals may use CPT codes to evaluate the efficiency and abilities of individuals or divisions within their facility. Each CPT code is five characters long, and may be numeric or alphanumeric, depending on which category the CPT code is in. CPT codes are divided into three Categories.

Category I is the most common and widely used set of codes within CPT. It describes most of the procedures performed by healthcare providers in inpatient and outpatient offices and hospitals. Category II codes are supplemental tracking codes used primarily for performance management. Category III codes are temporary codes that describe emerging and experimental technologies, services, and procedures. Note that while CPT codes have five digits, there are not 99,plus codes.

Like the ICD code set and its division into chapters by type of injury or illness, Category I CPT codes are divided into six large sections based on which field of health care they directly pertain to. The six sections of the CPT codebook are, in order:. CPT codes are, for the most part, grouped numerically. The codes for surgery, for example, are through In the CPT codebook, these codes are listed in mostly numerical order, except for the codes for Evaluation and Management.

State and federal government analysts use data from coding to track trends in medical care and to determine their budget for Medicare and Medicaid. CPT codes are found and used in various documentation as you transition through any health care experience. As you leave a healthcare provider's appointment or are discharged from a hospital or other medical facility, you are given paperwork that includes a numeric summary of the services they provided to you.

The five-character codes are usually CPT codes. There are other codes on that paperwork too, such as ICD codes , which may have numbers or letters and usually have decimal points. When you receive a bill from the healthcare provider, before or after it has been sent to your payer, it will have a list of services.

Next to each service will be a five-digit code. That's usually the CPT code. When you receive an explanation of benefits EOB from your payer, it will show how much of the cost of each service was paid for on your behalf. Like the healthcare provider's bill, each service will be aligned with a CPT code. Your interest in these codes is usually related to your healthcare providers' and insurance billings. The organization charges fees for the use of the codes and access to full listings, which means you won't find a comprehensive list online for free.

To make them more accessible to patients, the AMA provides a means for looking up the individual CPT codes you might encounter in medical paperwork.

If you have paperwork that has a CPT code on it and you want to figure out what that code represents, you can do so in a number of ways:. An important reason to try to understand CPT codes is so you can make sense of your hospital bill and catch any billing errors—which do happen often. These seemingly simple mistakes can have a big impact on your wallet. The wrong code can mean that your insurance won't cover any of the costs.

Try to take the time to sit down and slowly review your bill and compare it with your EOB to check for any possible errors. It is possible for your healthcare provider or the facility to make a typographical error, coding for the wrong type of visit or service.

There are also fraudulent practices like upcoding charging you for a more expensive service and unbundling billing bundled services or procedures as separate charges that should be on your radar.

When in doubt, don't be shy to call your provider to discuss any possible discrepancies. There are two levels of codes:. Examples of items billed with level II codes are medical equipment, supplies, and ambulance services. They can have modifiers that are either two letters or a letter and a number. Being an informed patient is part of ensuring you receive the best medical care.