CPT Code

Current Procedural Terminology codes are the standardized numeric codes used to describe medical procedures and services for billing purposes.

CPT codes are the language of medical billing. Every service you provide, from an office visit to a complex surgery, has a corresponding CPT code that you put on the claim. The payer uses that code to determine how much to pay you. CPT codes are maintained by the American Medical Association and updated annually. The codeset is divided into three categories. Category I codes are the main codes for procedures and services. They are five-digit numeric codes grouped by body system and type of service. Category II codes are supplemental tracking codes for quality measures. Category III codes are temporary codes for emerging technologies and services. The codes you use most frequently depend on your specialty. Primary care physicians live in the evaluation and management (E/M) codes: 99202-99215 for office visits, 99221-99223 for hospital admissions. Surgeons use codes from the 10000-69999 range. Radiology, pathology, and medicine each have their own sections. Correct coding is directly tied to correct payment. If you undercode (use a lower-level code than the service justifies), you leave money on the table. If you overcode (use a higher-level code than the documentation supports), you risk an audit, repayment demands, and potential fraud allegations. During credentialing, payers do not typically ask about your CPT coding practices. But once you are enrolled and billing, your coding patterns are tracked. Payers run statistical analysis comparing your coding distribution to peers in your specialty. If your average E/M level is significantly higher than the norm, expect a review. Stay current on CPT code changes. The AMA publishes updates every October for the following January. New codes are added, old codes are deleted, and existing codes are revised. Using a deleted code means an automatic denial.