CPT codes overview for medical billing

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Current procedural terminology (CPT codes) are numbers assigned to each task and service that a healthcare provider can provide to a patient, including medical, surgical, and diagnostic services. They are used by insurers to determine the amount of reimbursement the health care provider will receive from the insurer for this service.

Since they all use the same codes to mean the same thing, they provide consistency. CPT codes are used for both tracking and billing.

They are similar, but not completely identical to the codes associated with the General Health Care Procedures Coding System (HCPCS). If you use Medicare, you will see HCPCS codes on your documents instead of CPT codes.

Understanding CPT codes

The CPT code is a five-digit numeric code with no decimal places, although some contain four numbers and one letter. Codes are uniquely assigned to different actions. While some can be used from time to time (or some healthcare providers don't use them), others are used frequently (like 99213 or 99214 for general checkups).

CPT codes are designed, maintained, and copyrighted by the American Medical Association (AMA) . As health care practices change, new codes are developed for new services, current codes can be revised, and old codes that are not used are discarded. Thousands of codes are used and updated each year.

Consistency in what a service is and what different providers receive will not necessarily be the same. This is determined by contracts between individual providers and insurers.

For example, Provider A can perform a physical check (99396) and your insurance company will reimburse you $ 100. If you went to Provider B, your insurance company will reimburse you for the same verification / CPT code for only $ 90.

Laura Porter / Get Medication Information

Categories:

There are several categories of CPT codes, including :

  • Category I – Procedures, services, devices, and medications, including vaccines.
  • Category II: Performance indicators and quality of care
  • Category III: Services and procedures that use the latest technology
  • PLA codes, which are alphanumeric CPT codes used for laboratory testing.

Examples of

Here are some examples:

  • 99214 can be used to visit the office
  • 99397 can be used for routine checkups if you are over 65 years old.
  • 90658 indicates flu vaccine
  • 90716 can be used for chickenpox (chickenpox) vaccine
  • 12002 can be used when a healthcare provider sews a 1-inch cut on the arm.

Some CPT codes indicate packet services . That is, a code describes several aspects of care that are combined.

How CPT codes are used

Since CPT codes directly affect how much a patient will pay for healthcare, offices, hospitals, and other healthcare facilities are very strict about how the coding is done. They usually use professional medical coders or coding services to ensure correct coding of procedures.

Initial coding

Your healthcare provider (or their office staff) usually starts the coding process. If they use paper meeting forms, they will manually mark which CPT codes apply to your visit. If they use an electronic medical record (EHR) during their visit, this will be recorded in this system; Systems generally allow staff to easily call codes based on the name of the service.

Checking and shipping

After leaving a healthcare provider's office, medical coders and accountants check their records so they can assign the correct codes if they haven't already.

The billing department then sends a list of the services that have been provided to your insurance company or the payer. Healthcare providers and institutions often use electronic means to store and transmit this information, although some of this can still be done by mail or fax.

Claims handling

Your health plan or the payer then uses the codes to process your claim and determine the amount of reimbursement from your provider and the amount you owe.

Investigate

Coding data is used by health insurance companies and government statisticians to predict future health care costs for patients in their systems. State and federal government analysts use coding data to track health care trends and determine your Medicare and Medicaid budgets.

Where will you see the CPT codes?

CPT codes can be found and used in a variety of documentation as you advance in your medical experience.

Document excerpt

When you leave a doctor's appointment or leave a hospital or other health care facility, you are given papers that include a numerical summary of the services that have been provided to you.

Five-digit codes are usually CPT codes. There are other codes in these documents as well, such as ICD codes , which can be numbers or letters and generally have decimal points.

Accounts

When you receive a bill from a healthcare provider, before or after it is sent to your payer, the services will be listed. Each service will have a five-digit code next to it. This is usually the CPT code.

Explaining the benefits

When you receive an Explanation of Benefits (EOB) from your payer, it will show you how much of the cost for each service was paid on your behalf. Similar to a healthcare provider bill, each service will be combined with a CPT code.

Assignment of CPT codes to services

Your interest in these codes is generally related to bills from your healthcare providers and your insurance . CPT codes are copyrighted by AMA. The organization charges a fee for the use of codes and access to complete lists, which means that you will not find a complete list online for free.

To make them more accessible to patients, the AMA provides a means of finding individual CPT codes that can be found in medical records. If you have documents that have CPT code and you want to know what that code represents, you can do it in several ways:

  • Look up the CPT code on the American Medical Association website . You will need to register (free) and you are limited to five searches per day. You can search for the CPT code or use a keyword to find out what the associated CPT code might be for a service.
  • Contact your healthcare provider's office and ask them to help you match CPT codes and services.
  • Contact your billing staff and ask them to help you.
  • Remember that some codes can be combined, but can be searched in the same way.

Avoid incorrect coding

An important reason to try to understand CPT codes is that you can sort your hospital bill and spot any billing errors that occur frequently. In fact, some patient advocacy groups point out that nearly 80% of bills contain minor errors.

These seemingly simple mistakes can have a huge impact on your wallet. An incorrect code may mean that your insurance will not cover any costs.

Try to take the time to sit down and slowly review your bill and compare it to your EOB for possible errors. Your health care provider or institution may be misspelled or indicate the wrong type of visit or service.

There are also fraudulent practices such as encryption (charging a fee for a more expensive service) and splitting (services or billing procedures in separate fees) that should be at your disposal. If in doubt, feel free to call your supplier to discuss possible inaccuracies.

HCPCS codes

HCPCS codes are used and maintained by the Centers for Medicare & Medicaid Services (CMS) and are used to bill Medicare, Medicaid, and many other third party payers.

There are two levels of codes:

  • Level I codes are based on CPT codes and are used for services and procedures typically provided by healthcare providers.
  • Level II codes cover medical services and procedures that are not provided by health care providers.

Examples of items for which Level II codes are specified are medical equipment, supplies, and ambulance services. HCPCS Level II codes begin with a letter and have four digits. They can have modifiers that consist of two letters or a letter and a number.

HCPCS Level II code lists can be found on the CMS website . Level I codes, however, are protected by WADA copyright, as is CPT.

Get the word of drug information

Being an informed patient is critical to ensuring that you receive the best possible medical care. If you see something you don't understand in your medical record or on your bill, talk to your doctor or insurer. You have the right to play an active role in ensuring that your health care is followed up accurately.

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