Ultimate Guide to CPT Codes in Medical Billing 

With multiple patients coming in at every hour, it might be hard to manually account for all services provided and draw up the bills. 

However, CPT codes are here to make medical billing much more accessible. 

What are CPT Codes in Medical billing?

Current Procedural Terminology (CPT) Codes are a set of medical codes that offer a uniform language to be used by all healthcare workers to report any procedure or services they provide. Each CPT code constitutes a written description of a healthcare service, eliminating any room for subjective interpretation of what was provided to the patient, 

It is a uniform language that extends to all healthcare departments (medical, surgical, radiology, anesthesiology, laboratory, etc). CPT codes also aid administrative work like claim processing and billing. 

CPT codes were curated by the American Medical Association (AMA) in 1966 to standardize reporting of healthcare (medical, surgical, and diagnostic) services, whether in outpatient or inpatient settings. 

CPT codes are not set in stone. Thousands are updated every year. They are prone to revision, and unused codes can be thrown out.

Common Types of CPT Codes in Medical Billing

The very first CPT codebook was 175 pages long and consisted of almost 3500 codes. Today, there are over 10,000 CPT codes. 

These codes are divided into three categories.

1. Category I

Category 1 codes are the most extensive and widely used set. They reflect descriptions of each service or procedure that the healthcare institution provides.

All category 1 CPT codes are numeric and consist of five digits. They are divided into six subcategories with ranges;

• Evaluation and Management (99202–99499)
• Anesthesia (00100–01999)
• Surgery (10004–69990) — further broken into smaller groups by body area or system within this code range
• Radiology (Including Nuclear Medicine and Diagnostic Ultrasound) (70010–79999)
• Pathology and Laboratory (80047–89398)
• Medicine (90281–99199, 99500-99607)

Each of these fields has its specific guidelines for use. For instance, the Surgery section includes guidelines for reporting additional materials used (such as sterile trays or medications) and documenting follow-up care for surgical procedures. 

2. Category II

Category II codes, composed of four numbers followed by the letter F, are supplementary tracking and performance measurement codes that providers can use alongside Category I codes. Unlike Category I codes, Category II codes are not tied to reimbursement.

Providers utilize Category II codes to track specific patient information, such as tobacco use, to enhance healthcare delivery and improve patient outcomes.

A few category examples are: 

• Composite Codes (0001F–0015F)
• Patient Management (0500F–0584F)
• Patient History (1000F–1505F)
• Physical Examination (2000F–2060F)

3. Category III

Category III codes, represented by four numbers followed by the letter T, generally appear after Category II codes in the code book. These temporary codes identify new technologies, services, and procedures.

New services and procedures can be classified under Category III for up to five years. If these services and procedures meet the criteria for Category I — including FDA approval, widespread provider use, and proven effectiveness — they will be reassigned Category I codes.

If providers do not use them, Category III codes may be removed.

3. Proprietary Laboratory Analyses (PLA) codes

Recently added to the CPT code set, these codes describe proprietary clinical laboratory analyses. They can be provided by a single (“sole-source”) laboratory or licensed and marketed to multiple laboratories approved by the Food and Drug Administration (FDA). 

This category includes, but is not limited to, Advanced Diagnostic Laboratory Tests (ADLTs) and Clinical Diagnostic Laboratory Tests (CDLTs), as defined under the Protecting Access to Medicare Act of 2014 (PAMA).

Uses of CPT Codes

1. Initial Coding: 

As soon as a patient visits a hospital, the CPT codes for his services are manually noted via paper encounter forms or an electronic health record (EHR). Corresponding to the service, a CPT code is generated. 

This process can be automated if an electronic system helps the employees quickly and smoothly refer to codes based on the name of the service.  

2. Verification and submission: 

The patient’s record must be thoroughly analyzed and assessed to assign the codes. A list of all provided services and treatments is drawn and submitted to the insurance company or payer. 

Most healthcare providers typically use electronic methods to transfer or store this information. Sometimes, a facility may still utilize fax or standard mailing services.

3. Claim Processing: 

CPT Codes are required to process a claim, determine the reimbursement levels a healthcare provider needs, and calculate the amount that a patient owes. Specialized providers, such as Chiropractic Billing Companies, often rely on accurate CPT coding to streamline claim submissions and ensure timely reimbursements for chiropractic care service

4. Research: 

To figure out the future financial trends in the healthcare department, coding statistics are used by Government statisticians and health insurance companies.

Along with this, coding data is also used by federal and state government analysts to inspect trends in healthcare to work out a suitable budget for government-funded programs like Medicaid and Medicare.

What is a CPT Modifier?

Medical procedures are often long and complicated, with multiple nitty gritty. This is why CPT Modifiers are used to enhance CPT codes.

As in English, a simple modifier may express details like the who, what, how, why, or where of a particular situation. Similarly, a CPT modifier can tell us the number of procedures performed, the extent of the procedure’s necessity, what body part it was performed on, the number of surgeons involved, and other crucial information that may affect the claim to be submitted to the insurance payer. 

CPT modifiers are generally denoted by letters or numbers. For instance, the modifier -22 reflects increased services, while -52 means decreased fees. 

Ten Most Commonly Used CPT Codes 

1. 90837: 60-minute psychotherapy

This records a face-to-face therapy session with a patient, lasting for at least 53 minutes. 

2. 90834: 45-minute psychotherapy

This reflects a shorter therapy session of around 38-52 minutes.

3. 90832: 30-minute psychotherapy

This code is for an even shorter time of around 16-37 minutes of face-to-face therapy.

4. 90791: Psychiatric diagnostic evaluation

This indicates the initial client assessment, in which a diagnosis is drawn up before the treatment starts. 

5. 90792: Psychiatric diagnostic evaluation (with medical services)

This involves an assessment, diagnosis, and a treatment plan after the initial evaluation.

6. 99203–99205 and 99213–99215: E/M codes

These include services where a qualified healthcare professional makes a diagnosis and treats an illness.

7. 90833, 90836, and 90838: Individual psychotherapy add-on codes (for use with E/M codes)

This is applied to a physiotherapy service in addition to an evaluation or management appointment.

8. 90846: Family psychotherapy (without patient present)

This is applied to a 50-minute physiotherapy session where the focus is on a family or partnership equation in the client’s absence.

9. 90847: Family psychotherapy (with patient present)

This indicates a 50-minute family physiotherapy session with the identified client present. 

10. 90785: Interactive complexity

This is an add-on code that is applied to those physiotherapy sessions that require a little extra work due to communication difficulty (for instance, when dealing with clients with deteriorated mental health).

Bottomline

CPT codes drive medical billing, enabling medical providers to generate sufficient revenue. 

Any inaccuracy or mistake in applying these codes can lead to drastic consequences, so they must be handled very carefully.