CPT Codes in Medical Coding – Everything You Need To Know

Are you getting mixed up about CPT codes in general? This blog will clear all your concepts with an extensive explanation about them. We will cover everything about their types, guidelines, examples, challenges, and more.

So, don’t miss out on such a great learning experience about CPT codes. Contact Health Quest Billing and get your medical coding process sorted through our expert coders.  

What Are CPT Codes?

The full form of CPT in medical coding is Current Procedural Terminology. This name is associated with specific numeric codes that are assigned to medical services. These CPT codes are important for healthcare providers and insurance companies.

They use them to identify specific healthcare procedures while billing them. The American Medical Association develops and maintains all CPT codes. Their purpose is to standardize the medical billing and coding processes and prevent errors.

Types of CPT Codes

Each CPT code accurately describes its specific medical procedure. Those procedures can be diagnostic tests, routine check-ups, therapy sessions, and others. CPT codes accurately and consistently record their healthcare data.

They also ensure that the relevant claims are processed properly. The process can be different for Medicare, Medicaid, and other health insurance programs. Generally, CPT codes come under four categories. Let’s take a look at those categories in detail:

• Category 1

Most of the current CPT codes come under Category 1. It includes codes for commonly performed procedures and services. Its codes are five-digit numeric and range from 00100–99499. A large part of those codes are represented under subcategories.

These subcategories are based on the service type. For that, a descriptor nomenclature is commonly included. The policies set for this category state that similar codes should be clustered in sequences.

However, a sequence can break upon the addition of a new code if a sequential number is unavailable. This usually happens with evaluation and management (E/M) codes. Category 1 codes are widely accepted by a range of entities.

New CPT codes are added to Category 1 annually. Its codes represent six medical sections: evaluation and management, anesthesia, and surgery. The other sections are radiology, medicine, pathology, and laboratory.

• Category 2

The codes in Category 2 are supplementary tracking codes. They are assigned to measure the performance of health outcomes and care quality. The usage of Category 2 codes is optional. They cannot be considered as substitutes for Category 1 codes.

They are usually assigned alongside Category I codes but cannot replace them. Moreover, Category 2 codes are not linked to reimbursements. They are alphanumeric and consist of four numbers. Ending with the letter F, they appear below Category 1 codes in the CPT codebook.

Category 2 codes represent various sections like patient history and composite measures. Some other sections comprise physical examination, patient management, diagnostic processes, and preventive interventions.

• Category 3

Category 3 has temporary tracking codes that cover the latest medical technologies. They are also associated with specific healthcare services and procedures. Category 3 codes follow the Category 2 ones in the CPT codebook.

They are assigned to those services that might not be widely provided. Those services might also not be approved by the FDA. It is also possible that their clinical efficacy is not proven. Each Category 3 code consists of five digits.

They have four numbers and end with the letter T. These codes are assigned to track new technologies. They are also assigned to services that do not align with Category 1 codes. The services, assigned with Category 3 codes, may be reassigned to Category 1 codes.

This happens when those services receive FDA approval. Another case is if they are widely performed by many providers. The American Medical Association releases a revised list of Category 3 codes semi-annually.

PLA Codes

Laboratory testing has always remained a vital diagnostic procedure in medical billing. The full form of PLA is Proprietary Laboratory Analyses. Its codes are assigned to various lab tests. By using these codes, healthcare providers ensure that every test has a unique identifier. Such unique identifiers are important to generate precise medical bills.

How to Recognize CPT Codes?

Unlike ICD codes, the numbers and characters in CPT codes do not correspond to specific procedures. AMA has carefully developed CPT codes to enable flexibility and revisions. Those revisions and CPT code set maintenance have to be undertaken by the CPT Editorial Panel.

This Panel is appointed and authorized by the AMA Board of Trustees. CPT advisors and groups of physicians support that Panel. Those physicians are clinical experts in their medical fields. You must regularly review CPT codes to ensure that you issue clinically valid codes.

They must be updated and maintained so that a widely accepted medical nomenclature is used. This enables the usage of that nomenclature in the U.S. for healthcare services.

Guidelines for Assigning CPT Codes

There are various guidelines that have to be followed while assigning CPT codes. These guidelines keep your billing processes accurate and compliant. Each guideline serves a specific purpose to ensure integrity. Here is a detailed explanation of the major guidelines:

• Code Specificity

Code specificity is based on the level of detail used by healthcare providers. Those details correspond to the selection of a CPT code. Its selection describes a specific diagnosis, service, or procedure. You must always assign the most specific code possible.

It should accurately reflect your patient’s condition along with your services. You can only use general or unspecified codes if there are no specific codes available. An example of a general code is R10.9 for abdominal pain. Instead of that code, you can assign R10.11 which corresponds to right upper quadrant pain.

• Multiple Codes

Multiple coding means that healthcare providers assign multiple CPT codes. This is done to fully capture every aspect of their diagnosis and treatment. You may also come across cases where you have to report multiple procedures. In such cases, you must assign all necessary CPT codes to completely cover the scope of your medical care.

There are other conditions that require a primary code and secondary codes as well. Consider a patient treated for both hypertension and diabetes. They would require separate codes for each condition. One of the relevant codes is E11.9 for type 2 diabetes without complications. While the other CPT code will be I10 for hypertension.

• Modifiers

Modifiers are two-character codes so either numeric or alphanumeric. Healthcare providers add them to CPT or HCPCS codes. They provide extra details about the medical services provided. You must use modifiers in case of specific circumstances.

An example of such circumstances would be a service performed multiple times. It is also possible that a medical procedure was more complex than usual. The relevant service can also be provided by different healthcare providers.

In such cases, modifiers keep billing accurate and prevent claim denials. Modifier 25 is an example of modifiers which is used commonly. It indicates a separately identifiable evaluation and management service.

That medical service is provided on the same day of a procedure. Modifier 59 refers to the procedures that are usually not reported together. Those procedures are performed by healthcare providers under different circumstances.

• Bundling

In bundling, you have to combine several medical services into a single code. This is done to represent a comprehensive package of care through those services. You should avoid assigning separate codes for services that are typically included in a single package.

Unbundling can cause claim denials and even fraud accusations on healthcare providers. An example of bundling is a minor surgical procedure which includes local anesthesia. You should not code anesthesia separately. This is because it is included in the procedure’s code.

• NCCI Edits

The full form of NCCI edits is the National Correct Coding Initiative edits. They are rules set by CMS to prevent improper coding. Such codes can result in incorrect payments in Medicare Part B claims. You should follow these edits to avoid billing services that should not be billed together.

Those services are also considered components of more comprehensive medical services. As a result, the edits can prevent double billing, commonly known as upcoding. Two codes can be listed as mutually exclusive under NCCI edits.

In this case, you should only report the appropriate code for the service provided. For example, code pair edits can prevent billing a comprehensive procedure. They can also prevent the billing of that procedure’s component service.

Examples of CPT Codes

We have described four commonly assigned CPT codes for you. Take a look at the descriptions below:

• CPT Code 33275: This code is assigned whenever a permanent leadless pacemaker is removed. It is removed from the right ventricle using a transcatheter approach.
• CPT Code 3006F: This code reports the documents and reviews of chest X-rays. Those X-rays are specifically conducted on Community-Acquired Pneumonia patients.
• CPT Code 0510T: This code is assigned to the surgical removal of an implant from the sinus tarsi. It is a small cavity located on the lateral side of the foot between the talus and calcaneus bones.
• CPT Code 0079U: This code is assigned to a genetic test that uses multiple selected single-nucleotide polymorphisms. They are used to perform comparative DNA analysis.

Challenges of Assigning CPT Codes

The process of assigning CPT codes is rigged with serious challenges that can affect both clinical and financial outcomes. Here is an explanation of those challenges:

• Payer-Specific Guideline Compliance: Different insurance companies have their own coding requirements. It can be challenging to be familiar with all those rules as they can vary significantly.
• Understanding NCCI Edits: A high level of expertise is required to accurately follow NCCI edits and prevent improper coding.
• Team Coordination: It can be challenging to maintain effective communication between your coding and billing teams to ensure that proper CPT codes are assigned.
• Audits and Compliance Issues: Incorrect CPT codes can land you in heaps of audits and compliance issues. Consistent errors may be viewed as fraud or abuse as well.
• Time Constraints and High Workload: Medical coders often have to work under tight deadlines and heavy workloads. This especially happens in high-volume healthcare settings.

How to Overcome Those Challenges?

We won’t leave you stranded with just the challenges as we have provided their solutions as well. Let’s take a look at them:

• Payer-Specific Guideline Compliance: Develop a centralized database of payer-specific coding requirements that is easily accessible to coders for quick reference.
• Understanding NCCI Edits: Implement software tools that automatically check for NCCI edits and alert coders to potential issues or incorrect combinations.
• Team Coordination: Establish regular meetings between clinical, coding, and billing teams to discuss complex cases and coding issues.
• Audits and Compliance Issues: Set up internal auditing programs to catch errors before external auditors flag them and provide corrective action plans.
• Time Constraints and High Workload: Use advanced coding software to automate repetitive tasks and allow coders to focus on complex cases.

The Bottom Line

This blog covered CPT codes along with their types and how to recognize them. We also discussed the guidelines that you must keep in mind while assigning them. We gave some examples of CPT codes as well as the challenges that come with them.

In the end, the blog highlighted how you can overcome those challenges. Contact Health Quest Billing to ensure that you always assign accurate CPT codes to your medical services.