What is CPT (Current Procedure Terminology) - US Medical Billing

 

 Current Procedure Terminology

 

 Precision and accuracy are key factors in medical billing. Insurance companies rely on this system to quickly process claims, and healthcare providers require a standardized mechanism to communicate the services they offer. CPT, or Current Procedural Terminology, enters the picture in this situation. We'll go into the realm of CPT and its crucial function in medical billing in this succinct blog post.

 

What is CPT?

The American Medical Association (AMA) is responsible for maintaining and developing the CPT system of medical codes and descriptors. These codes are employed to provide standardized descriptions of the medical treatments, services, and tests carried out by healthcare professionals. Healthcare professionals, insurance providers, and government organizations can communicate about healthcare using CPT codes.

 

Key points to understand about CPT

Universal Language: 

For healthcare providers, payers, and regulators, CPT codes act as a universal language. Regardless of location or specialty, they make sure that medical procedures and services are consistently and accurately represented.

Coding System:

CPT codes follow an alphanumeric coding scheme and typically have five characters. Three categories have been established for them.

Billing and Reimbursement:

CPT codes are essential for the processes of medical billing and reimbursement. A healthcare professional will apply the appropriate CPT code when they provide a service or operation. To calculate the reimbursement amount that the provider is qualified to receive from insurance companies or government programs, these codes are included in insurance claims.

Accuracy is Key:

To avoid claim denials and guarantee correct compensation, accurate coding is crucial. To appropriately classify operations, medical coders and healthcare professionals must stay informed of CPT code updates and requirements.

 Regulatory Compliance:

CPT coding is important for auditing and regulatory compliance. It makes sure that medical services are billed and recorded in conformity with rules and regulations that have been set down.

Electronic Health Records (EHRs): 

CPT codes are frequently integrated into electronic health record (EHR) systems, which makes it simpler for healthcare professionals to appropriately document and code services. The billing procedure is streamlined and error-prone thanks to this integration.

Medical Research and Analysis:

CPT codes are used for medical research and study of the healthcare system. They make it possible for researchers and analysts to monitor patterns in the use of healthcare, the effectiveness of treatments, and the frequency of particular procedures.

The Structure of CPT Codes

CPT codes are typically five-digit alphanumeric codes. They are organized into three distinct categories:

Category I Codes: 

The most prevalent CPT codes, or Category I codes, include a wide range of medical operations and services. They range from standard check-ups to surgeries and diagnostic tests.

Category II Codes:

These codes are optional and are used to monitor clinical outcomes and performance metrics. They offer further details regarding the standard of the care delivered.

Category III Codes:

These short-term designations are used to novel practices, methods, and services. They support the data collection and monitoring of the application of novel and experimental therapies.

 

Use of CPT Codes in Medical Billing

Medical billing and healthcare reimbursement depend greatly on CPT codes. The procedure is as follows:

Service Documentation: 

A healthcare professional must use the correct CPT code to record each service or procedure they carry out. The specific service provided is described by this code.

Claim Submission: 

The provider sends a claim with the appropriate CPT code(s) to the patient's insurance provider or payer.

Processing of Claims: 

The insurance provider examines the claim, confirms the CPT codes, and establishes the coverage and amount of reimbursement in accordance with their fee schedule.

Payment and Reimbursement: 

If the insurance company approves the claim, the provider will be paid in accordance with the negotiated reimbursement rates for the utilized CPT codes.

 

The Value of Accuracy

Medical billing relies heavily on accurate CPT coding. Claims denials, payment delays, and even legal problems can result from incorrect coding. To guarantee correct billing and reimbursement, it is crucial for healthcare professionals to be informed about CPT code changes.

Certainly! Examples of CPT codes for various medical procedures and services are shown below:

Routine Office Visit - CPT Code: 99213

Office or other outpatient visit for the evaluation and management of an established patient, typically lasting 15 minutes.

Electrocardiogram (ECG or EKG) - CPT Code: 93000

Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report.

Laparoscopic Appendectomy - CPT Code: 44970

Laparoscopic removal of the appendix.

MRI of the Brain - CPT Code: 70551

Magnetic resonance imaging (MRI) of the brain; without contrast material.

Colonoscopy - CPT Code: 45378

Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.

Physical Therapy Evaluation - CPT Code: 97161

Physical therapy evaluation, low complexity, requiring these components: a history with no personal factors and/or comorbidities that impact the plan of care.

Flu Vaccine Administration - CPT Code: 90471

Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid).

Emergency Room Visit - CPT Code: 99285

Emergency department visit for the evaluation and management of a patient, including a comprehensive history, examination, and medical decision-making of high complexity

Psychiatric Diagnostic Interview - CPT Code: 90791

Psychiatric diagnostic interview examination, without medical services, includes a comprehensive assessment of history, mental status, and a disposition.

Cardiac Bypass Surgery - CPT Code: 33533

Coronary artery bypass, using arterial graft(s); three arterial grafts.

These are just a few examples of CPT codes used in medical billing to describe a range of medical procedures and services. Each code corresponds to a specific medical activity or treatment, and they are used to ensure accurate billing and reimbursement in the healthcare industry. Please note that CPT codes can change and may have additional modifiers or variations depending on specific circumstances and provider documentation.

 

New Patient Visit (New Visit CPT Codes)

CPT Code Range: 

New patient visit CPT codes generally fall within the range of 99201 to 99205 for office or outpatient visits.

These codes are used when a patient is seeing a specific provider for the first time or has not received any services from that provider within the past three years. It signifies that a new patient-provider relationship is being established

 

Established Patient Visit (Established Visit CPT Codes)

CPT Code Range: 

Established patient visit CPT codes generally fall within the range of 99211 to 99215 for office or outpatient visits.

These codes are used when a patient has an existing and on-going relationship with the healthcare provider, having received services from the same provider within the past three years.

 

In conclusion, the Current Procedural Terminology (CPT) standardized coding system is used in the healthcare industry to accurately describe and report medical procedures and services. Medical billing, insurance claims, regulatory compliance, and healthcare research all depend on it to make sure that healthcare practitioners are fairly compensated and that medical data is reliably documented and evaluated.