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What are Current Procedural Terminology codes?

CPT or Current Procedural Terminology codes are numbers allocated to every medical, surgical and diagnostic service prescribed to a patient by a healthcare professional. CPT is also used for administrative tasks such as health insurance claims, billing, and developing standards for medical care review. These CPT codes were first developed by American Medical Association (AMA) in 1966 and were initially created for surgical procedures after which it was modified to include billing and health insurance. The codes are reviewed and renewed every year by the CPT Editorial Panel. 

The CPT codes are regularly updated to keep up with the ongoing research and advancements in the medical field and to ensure the accurate functioning of medical practices. According to AMA, CPT codes are a medical language that has become the standard for communicating medical terms and necessities among various healthcare teams, health systems and insurance companies. The CPT codes are usually a set of five numbers having no decimal point, however, in some cases, they can be alphanumeric in nature. 

CPT codes are universal thus rendering them uniformity. They help with tracking and billing purposes. The codes help to understand what services the patients requested and used previously as well as currently by accessing patient history that is present in the Electronic Health Records. Since CPT codes determine the medical bills the patients have to pay, offices, hospitals, and other medical facilities ensure that the coding is stringent and accurate. They employ professional medical coders or coding services to make sure that the procedures are coded correctly. 

Current Procedural Terminology codes are different from ICD codes. CPT codes are for services and procedures and ICD codes are for diagnostic purposes. CPT codes describe the procedure a patient has received while ICD codes describe the diseases, illnesses or injuries a patient may have. Current Procedural Terminology coding is similar to ICD-9 and ICD-10 coding, except that it identifies the services rendered, rather than the diagnosis on the claim (ICD-10-CM was created for diagnostic coding- it took the place of Volume 3 of the ICD-9). The ICD code sets also contain procedure codes (ICD-10-PCS codes), but these are only used in the inpatient setting. Although several ICD codes do cover medical claims and insurance, CPT codes give a clearer picture of billing and returns. 

CPT codes are divided into three categories:

  1. Category 1: These codes correspond to a procedure or services and range from 00100 to 99499. This category includes codes for six sections: evaluation and management, anesthesiology, surgery, radiology, pathology and laboratory, and medicine. 
  2. Category 2: This includes additional tracking codes that are required for understanding performance measures and assessing the quality of care provided. This category is an optional set. 
  3. Category 3: This includes codes for all the latest and emerging technologies. The services or the procedures involved in this category need not be FDA approved and are usually part of ongoing research or clinical trial. There is a five-year limit after which these codes can either be dropped or adopted into category 1. 
  4. Another category of the CPT codes includes the Proprietary Laboratory Analysis (PLA) codes which were recently added. The PLA code encompasses all the clinical laboratory analyses provided either by a single laboratory or marketed by multiple FDA-approved laboratories. 

Some of the most commonly used CPT codes include: 

  • New patient office visit codes: used to bill patients who have not visited a physician in a speciality in the last three years
  • Established patient office visit codes: used to bill patients that have visited a physician in the same speciality in the last three years
  • Initial hospital care for new or established patients codes: used to bill for patients that are admitted to a hospital
  • Subsequent hospital care codes
  • Emergency department visit codes
  • Office consultation codes: used for patients seeking the opinion of a physician at the request of another physician

The AMA system provides a standard language and numerical coding methodology to communicate the medical, surgical, diagnostic, and therapeutic services provided by healthcare professionals across various departments, patients and stakeholders. The CPT descriptive terminology and associated code numbers are the most widely accepted medical nomenclature used to report medical procedures and services for processing claims, conducting research, evaluating healthcare utilization, and developing medical guidelines and other forms of healthcare documentation.

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