What are CPT Codes in Medical Billing?

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Current Procedural Terminology, or CPT codes in short, are the kinds of codes that are used to report a few things such as medical, surgical, and diagnostic procedures and services to several parties such as physicians, health insurance companies, and accreditation organizations. Normally, they are used in conjunction with ICD-9-CM or ICD-10-CM numerical diagnostic coding during the process of the electronic medical billing.

CPT codes are often mistaken as ICD codes when in fact these two are two different things. Basically, the difference between these two are that the CPT codes are related to procedures while the ICD codes are the ones that are related to diagnoses. CPT codes, which can also be called procedural codes, are the ones that describe what type of procedure that has been received by a patient while ICD codes, which are also known as diagnostic ones, are the one that describe any diseases, illness or injuries a patient may have.

What are CPT Codes in Medical Billing
While you might think you are not familiar with the CPT codes, you might have seen it at least once. Where do you think you see such codes? These kinds of codes are usually found and used in a few documents as you transition through any health care experience. These documents include discharge paperwork, bills, and explanation of benefits. You can check out these documents if you want to see how they look.

CPT codes have a total of three variations, including Category 1, category 2, and Category 3. For those who want to know these variations, check out these followings:

Category 1: Procedures and contemporary medical practices

Procedures and contemporary medical practices that are widely performed are two things that are covered by this category. This one is the section that is usually identified by the coders when speaking about CPT. They are five digit numeric codes that identify either a procedure or a service that is approved by the Food and Drug Administration or FDA. The ones that perform it are the healthcare professionals nationwide. It is also proven and documented.

This category is divided into six sections, which include:

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

Category 2: Clinical Laboratory Services

In this category, there are the supplementary tracking codes. These kinds of codes are usually used for performance measures and the aim of these is to help collect information about the quality of care delivered. Keep in mind that it is not a must to use this medical code set, meaning it is optional. Not only that, it is also not considered as a substitute for Category 1 codes.

Category 3: Emerging technologies, services and procedures

The list of the CPT code is Category 3 includes the temporary codes that cover emerging technologies, services, and procedures. They are not the same as the one included in the Category 1 as they identify the services that may not be done by many healthcare professionals, may not be approved by the FDA, and may have not been proven clinical efficacy. In order to meet the requirements, it is a must for the service or procedure to be involved in the ongoing and planned research. These CPT codes have the main aim to help the researchers to track the emerging technologies and services.

Below are some examples of the CPT codes:

  • 99214 is the one that may be used for an office visit.
  • 99397 is the one that may be used for a preventive exam if you are more than 65.
  • 90658 is the one that indicates a flu shot.
  • 90716 is the one that may be used for chickenpox vaccine or varicella.
  • 12002 is the one that may be used in a situation when a healthcare provider stitches up a 1-inch cut on your arm.

It should be noted that some of the CPT codes indicate the bundled services. It means a code can describe a number of aspects of care that are performed in combination.

How are the CPT codes used? Due to the fact that CPT codes can affect the amount of money that will be paid by a patient for medical care, hospitals, and some other medical facilities, coding should be done properly. To make sure that everything is done well without any mistakes, the professional medical coders or coding services are usually hired to work with the codes.

The coding process will usually be started by the healthcare provider. Sometimes, it is started by the office staff. If paper encounter forms are used, noting the CPT codes that apply to the visit will be done manually. If an electronic health record or EHR is used instead of the manual one, it will be noted in the system. Usually, the staff will be allowed by the system to easily call up the codes based on the service name. ‘

After leaving the office of the healthcare provider, it will be a time for the medical coders and billers to examine the records. During this time, they can assign the correct codes just in case it not done already.

Then, the billing department will submit a list of the services that have been provided. Usually, the one that is used by the healthcare providers and facilities to store and transfer this information is the electronic service. However, there are some that may still do it through mail or fax.

After that, the codes are used by the health plan or payer to process the claim and to determine the amount of reimbursement. The coding data is widely used by health insurance companies and government statisticians. They are useful to predict the cost of the health care for the patients in the systems that they have. For your information, the data from the coding is used by the state and federal government analysts to track the trends that are currently happening in medical care. Not only that, they are also normally used to determine their budget for Medicare and Medicaid.

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