Remember that you always need to code to the highest level of specificity, and a miscoded procedure can be the difference between an accepted and rejected claim. Each of these sections has its own subdivisions, which correspond to what type of procedure, or what part of the body, that particular procedure relates to.
The sections are grouped numerically, and, aside from Evaluation and Management, are in numerical order. Certain codes have related procedures indented below them. These indented codes are important variations on the code above them, and denote different methods, outcomes, or approaches to the same procedure.
For example, the code for the elevation of a simple, extradural depressed skull fracture is The code for the elevation of a compound or comminuted, extradural depressed skull fracture is There are a few important CPT Modifiers, which provide additional information about the procedure performed.
Some codes have instructions for coders below them. These instructions are found in parentheses below the code, and they instruct the coder that there may be another, more accurate code to use. These codes are five character-long, alphanumeric codes that provide additional information to the Category I codes. These codes are formatted to have four digits, followed by the character F.
These codes are optional, but can provide important information that can be used in performance management and future patient care. They are divided into numerical fields, each of which corresponds with a certain element of patient care. For a list of these fields in oder as well as examples, please refer to our ebook and powerpoints. Still, it is an important element of the CPT code set, and you should be familiar with the basics of Category II codes as you prepare for a career in the field.
The third category of CPT codes is made up of temporary codes that represent emergent or experimental services, technology, and procedures.
In certain cases, you may find that a newer procedure does not have a Category I code. Category III codes allow for more specificity in coding, and they also help health facilities and government agencies track the efficacy of new, emergent medical techniques.
This Panel mandates that procedures or services must be performed by a number of different facilities in different locations, and that the procedure is approved by the FDA. Think of the sunset dates as expiration dates on the code. These codes are not billable for reimbursement. Category III CPT codes are used for reporting emerging technology in a number of capacities including services or procedures recently performed on humans, clinical trials and etc.
These codes are temporary codes and must be accepted for placement in Level I within five years, be renewed for another five more years, or be removed from the book. CPT Code Revisions: These codes are constantly being removed, revised, updated and added each October with the exception of emerging technology and vaccines, which are updated every six months. Your healthcare provider or her office staff will usually start the coding process.
If they use paper encounter forms, they will manually note which CPT codes apply to your visit. If they use an electronic health record EHR during your visit, it will be noted in that system; typically, systems allow staff to easily call up codes based on the service name. After you leave the healthcare provider's office, your records are examined by medical coders and billers so they can assign the correct codes, if not done already. The billing department then submits a list of the services you were provided to your insurer or payer.
Healthcare providers and facilities generally use electronic means to store and transfer this information, although some may still be done by mail or fax. Your health plan or payer then uses the codes to process the claim and determine how much to reimburse your healthcare provider and how much you may owe. Health insurance companies and government statisticians use coding data to predict future health care costs for the patients in their systems. State and federal government analysts use data from coding to track trends in medical care and to determine their budget for Medicare and Medicaid.
CPT codes are found and used in various documentation as you transition through any health care experience. As you leave a healthcare provider's appointment or are discharged from a hospital or other medical facility, you are given paperwork that includes a numeric summary of the services they provided to you.
The five-character codes are usually CPT codes. There are other codes on that paperwork too, such as ICD codes , which may have numbers or letters and usually have decimal points. When you receive a bill from the healthcare provider, before or after it has been sent to your payer, it will have a list of services.
Next to each service will be a five-digit code. That's usually the CPT code. When you receive an explanation of benefits EOB from your payer, it will show how much of the cost of each service was paid for on your behalf. Like the healthcare provider's bill, each service will be aligned with a CPT code. Your interest in these codes is usually related to your healthcare providers' and insurance billings.
The organization charges fees for the use of the codes and access to full listings, which means you won't find a comprehensive list online for free. To make them more accessible to patients, the AMA provides a means for looking up the individual CPT codes you might encounter in medical paperwork.
If you have paperwork that has a CPT code on it and you want to figure out what that code represents, you can do so in a number of ways:. An important reason to try to understand CPT codes is so you can make sense of your hospital bill and catch any billing errors—which do happen often.
These seemingly simple mistakes can have a big impact on your wallet. The wrong code can mean that your insurance won't cover any of the costs. Try to take the time to sit down and slowly review your bill and compare it with your EOB to check for any possible errors. It is possible for your healthcare provider or the facility to make a typographical error, coding for the wrong type of visit or service.
There are also fraudulent practices like upcoding charging you for a more expensive service and unbundling billing bundled services or procedures as separate charges that should be on your radar.
When in doubt, don't be shy to call your provider to discuss any possible discrepancies. There are two levels of codes:. Examples of items billed with level II codes are medical equipment, supplies, and ambulance services. They can have modifiers that are either two letters or a letter and a number.
Being an informed patient is part of ensuring you receive the best medical care.
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