What Is CPT®?

Integral to billing medical services and procedures for reimbursement,

Current Procedural Terminology (CPT)® is the language spoken between
providers and payers.
CPT® refers to a set of medical codes used by physicians, allied health
professionals, nonphysician practitioners, hospitals, outpatient facilities,
and laboratories to describe the procedures and services they perform.
Specifically, CPT® codes are used to report procedures and services to
federal and private payers for reimbursement of rendered healthcare.
In 1966, the American Medical Association (AMA) created CPT® codes to
standardize reporting of medical, surgical, and diagnostic services and
procedures performed in inpatient and outpatient settings. Each CPT® code
represents a written description of a procedure or service, removing the
subjective interpretation of precisely what was provided to the patient.
To accommodate the evolving world of healthcare — including the
availability of new services and the retirement of outdated procedures,
among other considerations — the AMA updates the CPT® code set
annually, releasing new, revised, and deleted codes, as well as changes
to CPT® coding guidelines. The AMA also releases smaller updates to
certain sections of the CPT® code set throughout the year.
The AMA updates CPT® nomenclature, or medical language, to reflect
advances in medicine. Although the AMA owns the copyright to CPT®, the
AMA invites providers and organizations to participate in the ongoing
maintenance of the code set, welcoming those who use it to suggest
changes to codes and code descriptors.
Recognizing CPT® Codes
CPT® codes consist of five characters. Most codes are numeric, but some
codes have a fifth alpha character, such as F, T, or U. Examples include:
33275 Transcatheter removal of permanent leadless pacemaker, right
ventricular, including imaging guidance (eg, fluoroscopy, venous
ultrasound, ventriculography, femoral venography), when performed
3006F Chest X-ray results documented and reviewed (CAP)
0510T Removal of sinus tarsi implant
0079U Comparative DNA analysis using multiple selected single-nucleotide
polymorphisms (SNPs), urine and buccal DNA, for specimen identity
verification
Understanding Types of CPT® Codes
Coders assign a code for every service or procedure a provider
performs. CPT® even includes unlisted codes for those services and
procedures not specifically named in another defined CPT® code.
Given the vast number of services and procedures, the AMA has
organized CPT® codes logically, beginning with classifying them into three
types:
1. CPT® Category I: The largest body of codes, consisting of those
commonly used by providers to report their services and procedures
2. CPT® Category II: Supplemental tracking codes used for performance
management
3. CPT® Category III: Temporary codes used to report emerging and
experimental services and procedures
Navigating Category I Codes
Most CPT® codes are Category I codes. These represent existing services or
procedures widely used and, when appropriate, approved by the U.S. Food
and Drug Administration (FDA).
With a few exceptions, Category I codes, typically denoted by five numeric
characters, are arranged in numerical order. One discrepancy to the
expected order involves resequenced codes. To give medical coders
convenient access to related codes — and thereby help in accurate code
selection — the AMA “clusters” similar codes together. A resequenced code
comes about when a new code is added to a family of codes, but a
sequential number is unavailable.
A second exception to numerical code order involves evaluation and
management (E/M) codes. As shown in the Category I code outline below,
E/M codes are printed first in CPT® code books, although they start with the
number nine. The AMA chose this order because E/M services are the most
often reported healthcare services. This arrangement, as with resequenced
codes, is designed for coding efficiency.
The six main sections of CPT® Category I codes and their sequences are:
1. Evaluation and Management (98000-98016, 99202-99499)
2. Anesthesia (00100-01999, 99100-99140)
3. Surgery (10004-69990) — further broken into smaller groups by body
area or system within this code range
4. Radiology (Including Nuclear Medicine and Diagnostic Ultrasound)
(70010-79999)
5. Pathology and Laboratory (80047-89398)
6. Medicine (90281-99199, 99500-99607)
Getting Acquainted With Category II Codes
Category II codes, consisting of four numbers and the letter F, are
supplemental tracking and performance measurement codes that
providers can assign in addition to Category I codes. Unlike Category I
codes, Category II codes aren't linked to reimbursement.
Providers use Category II codes — which track specific information about
their patients, such as whether they use tobacco — to help deliver better
healthcare and achieve better outcomes for patients.
Typically, Category II codes are found directly after the Category I codes in
the CPT® code book. These codes are arranged as follows:
1. Composite Codes (0001F-0015F)
2. Patient Management (0500F-0584F)
3. Patient History (1000F-1505F)
4. Physical Examination (2000F-2060F)
5. Diagnostic/Screening Processes or Results (3006F-3776F)
6. Therapeutic, Preventive, or Other Interventions (4000F-4563F)
7. Follow-up or Other Outcomes (5005F-5250F)
8. Patient Safety (6005F-6150F)
9. Structural Measures (7010F-7025F)
10. Nonmeasure Code Listing (9001F-9007F)
There are also Category II modifiers (1P-8P) that are reported only with
Category II codes, when required, and serve as denominator exclusions
from the performance measure.
Introducing Category III Codes
Category III codes, depicted with four numbers and the letter T, typically
follow Category II codes in the code book. Category III codes are temporary
codes that represent new technologies, services, and procedures.
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 include FDA approval, evidence
that many providers perform the procedures, and evidence that the
procedures have proven effective — they'll be reassigned Category I codes.
Conversely, Category III codes can be removed if providers don't use them.
The AMA releases new or revised Category III codes semiannually via their
website but publishes the Category III deletions annually with the full set
of temporary codes.
Learning How to Use CPT® Codes
Rules, notes, code descriptors, conventions, guidelines — there’s a lot for
new CPT® coders to digest.
First, procedural coding requires 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.
What's more, this knowledge of anatomy and medical terminology must be
thorough, as providers can perform services calling for CPT® codes from any
section in the code book. The codes a provider can report aren't 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.
Building Confidence With CPT® Coding Guidelines
The AMA provides CPT® coding guidelines that detail when and how to
assign codes, which codes can, and can’t be reported together, and other
factors critical to compliant coding.
It can't be emphasized enough to review the CPT® guidelines laid out in
each section, subsection, subheading, category, and subcategory before
trying to assign codes within that classification.
Equally important, before taking a coding position with the responsibility
of determining and reporting CPT® codes on medical claims, medical coders
should consider seeking proper training and credentialing. This is the best
way to ensure coding accuracy and optimal reimbursement for employers.
Appending Modifiers to CPT® Codes
Reporting CPT® codes requires familiarity with CPT® modifiers and their
use.
A CPT® modifier consists of two numbers, two letters, or a number and a
letter. Many situations require a coder to append modifiers to a CPT® code
to further describe the service or procedure provided. 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.
Some people may wonder why a CPT® code doesn’t include the additional
information provided by a modifier. It's because CPT® code books would be
too large and cumbersome if they contained a code for every scenario a
coder might encounter. A short list of modifiers goes a long way in
expanding the ability to report the unique circumstances of services and
procedures performed.
As with CPT® codes, the AMA creates and annually
maintains modifiers for CPT® coding. Coders will find these modifiers listed
in their CPT® code book. Payers may use modifiers differently, so it’s
important to verify each payer’s modifier requirements. And some codes
are “exempt” from certain modifiers, which the AMA indicates in the code
book.
Relating CPT® to Other Codes Sets
CPT® is just one of the many code sets used in healthcare. A few of the other
code sets are:
 HCPCS Level II: Used to report procedures, services, supplies, drugs,
and equipment
 ICD-10-PCS: Used by facilities to report inpatient procedures
(hospitals)
 ICD-10-CM: Used to report diagnoses for patients of inpatient or
outpatient providers
Distinguishing the difference between Healthcare Common Procedure
Coding System (HCPCS) Level II code use and CPT® code use can be
confusing.
When someone refers to HCPCS (pronounced "hick-picks"), they most likely
are referring to the HCPCS Level II code set. HCPCS Level I is the CPT® code
set. The main takeaway is that HCPCS Level II begins where CPT® ends.
The Centers for Medicare & Medicaid Services (CMS) wanted a
classification system for medical supplies, equipment, medications, and
services not included in CPT®, so around 1980 the AMA worked with CMS
to develop a new set of codes.
The resulting HCPCS Level II code set was originally used for Medicare
patients, but other payers found the codes useful and began requiring
providers to use them.
Examples of services, supplies, and items with HCPCS Level II codes include
orthotic and prosthetic procedures, hearing and vision services, ambulance
services, medical and surgical supplies, drugs, nutrition therapy, and
durable medical equipment.
CMS updates the HCPCS Level II code set quarterly, with the largest number
of changes often occurring in January.
Establishing Medical Necessity
Payers typically won't reimburse a provider for a claim unless the patient’s
diagnosis justifies the service or procedure that the provider performed.
This justification is called medical necessity, and this is where the
International Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM) coding ties in with CPT® coding (and HCPCS Level
II).
Every claim submitted for reimbursement will include one or more codes,
such as a CPT® code, for the service or procedure, as well as an ICD-10-CM
code(s) that reports the patient’s diagnosis to the highest level of
specificity.
The ICD-10-CM code (diagnosis) must establish medical necessity for
the CPT® code (service or procedure).
An example of a diagnosis and service meeting medical necessity is when a
patient comes into a medical office complaining of stomach pain, and the
physician conducts a physical examination. The stomach pain (diagnosis)
justifies the reason for the examination (service).
CPT® Coding Requires Current Code Books
For quick access to a list of CPT® codes and descriptions, working medical
coders typically use software with procedure code lookup, though these
tools are also available to students. The key to coding success is staying
current and always referencing the code sets that apply to the date of
service.
See the full list of CPT® codes by section.
CPT (Current Procedural Terminology)

[Link] I CPT Codes

Description: These codes are used for specific medical procedures and services provided by
healthcare professionals. They cover a wide range of activities, from office visits to complex
surgeries.
Examples:
99213: Established patient office or other outpatient visit, typically 15 minutes.

20610: Arthrocentesis, aspiration, or injection of a major joint or bursa, such as the knee or
hip.

[Link] II CPT Codes:

Description: These are used for reporting supplies, services, and products that are not
covered by Type I codes. They are often used for tracking and billing purposes rather than
describing procedures.
Examples:
A5500: Device used to correct foot deformity or support, such as custom diabetic shoes.
J codes Injectable drugs, like
J3301 for triamcinolone acetonide (Kenalog).

[Link] III CPT Codes:

Description: These codes were used for emerging technologies, services, and procedures
that may not yet be widely recognized or validated. Note that many Type III codes are now
obsolete or have been integrated into Type I codes as technologies become standard.
Examples:
0010T: Experimental or investigational procedures, like a new technology or treatment that
is still under evaluation.