CPT Medical Billing Codes

CPT stands for Current Procedural Terminology (4th edition) and is developed and maintained by the American Medical Association (AMA). It's also referred to as CPT-4 to denote the 4th (or current) edition of the category I codes.

This 5 digit code describes medical services performed by a physician or healthcare provider. They are also used for surgical and diagnostic services. All major commercial and government insurance carriers require the use of CPT codes. For example CPT-4 code 99243 is used for an initial office consultation and examination.

More information on Medical Billing Codes in general is available here.

Important For Reimbursement
CPT medical billing codes are assigned for every service a provider performs on or for a patient. These are services such as the evaluation of a patients condition, surgical procedures, or testing or diagnostic services. CPT codes are used by health insurers to determine how much a provider is reimbursed based on the services - or procedure - performed. Depending on the doctors contract with the insurance company, each provider may not be paid the same for the same procedure.

CPT codes correspond to an ICD-9 diagnostic code (soon to be ICD-10) which classify a disease or condition. For an insurance claim to be paid by the insurer, the CPT medical billing codes must appropriately match the ICD 9 (or ICD 10) diagnostic code. For example, the ICD 9 code for high blood pressure cannot be assigned a CPT-4 code for an unrelated treatment like an injection.

Where Can I Find CPT Medical Billing Codes?
The CPT medical billing codes are copyrighted by the AMA which prevents free use and distribution of codes without their permission and authorization.

However the AMA does allow a personal, non-commercial search of the Current Procedural Terminology (CPT) Codes on their website. The stipulation is that you that you can look up the codes only for personal information and cannot sell them.

If the AMA thinks you are using their free CPT search system too much, they can limit your searches and/or limit the number of CPT medical billing codes you look up at a time. You can look up CPT codes from the AMA search link available on our CPT medical coding free references page.

Three Categories of Codes
CPT medical billing codes are part of the HCPCS coding system. HCPCS consists of three levels:

• Level I - CPT Medical coding maintained by the American Medical Association.
• Level II - Alphanumeric codes used primarily to identify products, supplies, and services that are not included in the CPT codes, such as durable medical equipment, ambulance services, prosthetics, and supplies that are used outside of a providers office.
• Level III - Known as local codes. These were developed by state Medicaid agencies, Medicare contractors, and private insurers to use in certain programs. Level III codes were discontinued in 2003.

The AMA revises the CPT codes annually. CPT codes are sometimes accompanied by modifiers. These are two digit codes associated with a CPT code which indicate the procedure has been altered. These modifiers are described in appendix A of the CPT publication.

CPT medical billing codes submitted on an insurance claim are associated with the ICD-9 code to show the procedure is medically necessary. There may be more than one ICD-9 code associated with each CPT code. The CMS 1500 form can accommodate up to 4 ICD-9 codes in box 21 of the form as referenced by the diagnosis pointer in box 24E.

CPT Category I Code Organization

CPT codes are organized in sections as follows:

• Evaluation and Management - 99201 through 99499
• Anesthesia - 00100 through 01999
• Surgery - 10021 through 69990
• Radiology - 70010 through 79999
• Pathology and Laboratory - 80048 through 89399
• Medicine - 90281 through 99199

E/M Most Frequently Used
The Evaluation and Management codes, 99201 through 99499 are used by all specialties and facilities. These are listed first because they are the most commonly used. It's very important that these codes are accurately assigned because the majority of a practices income is based on these procedures.

The majority of E/M CPT medical billing codes require the provider to obtain information from the patient to access the necessary medical care. As such the E/M services are not significant procedures, but are important in determining the other procedures the patient needs.

CPT Symbols

Here are the symbols commonly used in CPT reference coding books:

• - Bullet to the left of the code denotes this is a new code that's never been used before.

Triangle - Located to the left of the code indicates the code description has been revised in the current edition of the CPT.

Two Horizontal Triangles - These are around notes that have been revised.

; - Semi-colon in a CPT description denotes that everything to the left of the semi-colon is applicable to the indented shorter descriptions following.

* - Asterisk or star shows after minor surgery codes to show preoperative and postoperative services are included and means the package or global surgery is not applicable. These procedures are usually paid as fee-for-service.

+ - Plus symbol identifies add-on codes usually performed at the same time and by the same provider as the primary procedure. There are usually notes in parenthesis to indicate the primary code(s) that these apply to.

Circle with line through it - Means modifier -51 is not assigned to the code and are not add-on procedures.

Lightning Bolt - Indicates product is pending FDA approval.

Dot surrounded by Circle - Denotes moderate sedation.

Free Billing Code Resources
Here's some links to free references for CPT medical coding and ICD 9 codes from reputable sites. These can be very helpful if you're just trying to do a quick search for a CPT or ICD-9 code.

Coding References
There are several CPT coding handbooks available in an easy to navigate format that provide clarifications and make it easier to associate the code with the description.

One of my favorite online coding resources is Supercoder. They have some great economical online coding reference products starting at $14.95 a month. They also have specialty coding libraries, a CPT medical billing codes assistant, and a "SuperScrubber" to reduce denials and optimize reimbursement.

I've found the the best paperback coding references for Medical Billing is the CPC-Current Procedural Coding Expert--latest edition, and the ICD-9-CM Expert for Physicians, Volumes 1 & 2-latest Edition. These are available on Amazon or any other medical reference bookseller. They are essential references for our medical billing business and are easy-to-navigate and laid out in a logical format with illustrations.

The CPT Expert combines codes with billing and Medicare regulatory information in one volume and clarifies annual code changes and rules. These references are also a great help in insuring the correct modifiers are used as this can be a big source of coding inaccuracies - and unpaid claims.

We occasionally find our clients using out of date CPT medical billing codes or situations where the ICD-9 codes don't match the treatment. Having good coding references is essential to resolving these issues.

Another excellent reference for medical billing specialists is Understanding Health Insurance.

It's an excellent source for describing CPT and ICD-9 coding systems, managed care, legal and regulatory issues, reimbursement methodologies, coding for medical necessity, and common health insurance plans. It's written in an easy to understand style for the complex issues in medical coding and billing and has several practical examples.

Medical Coding Software
This link discusses some of the options for Medical Coding Software and some of the major online resources available. Software references can be a real time saver in assigning the correct CPT medical billing codes.

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