Current Procedural Terminology Meaning

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TheCurrent Procedural Terminology (CPT) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency.

The CPT terminology is the most widely accepted medical nomenclature used across the country to report medical, surgical, radiology, laboratory, anesthesiology, genomic sequencing, evaluation and management (E/M) services under public and private health insurance programs.

The development and management of the CPT code set rely on a rigorous, transparent and open process led by the CPT Editorial Panel. Created more than 50 years ago, this AMA-convened process ensures clinically valid codes are issued, updated and maintained on a regular basis to accurately reflect current clinical practice and innovation in medicine.

All CPT codes are five-digits and can be either numeric or alphanumeric, depending on the category. CPT code descriptors are clinically focused and utilize common standards so that a diverse set of users can have common understanding across the clinical health care paradigm.

For more than 50 years, CPT has been the primary medical language used to communicate across health care, enabling seamless processing and advanced analytics for medical procedures and services. The CPT code set is constantly updated by the CPT Editorial Panel with insight from clinical and industry experts to reflect current clinical practice and the latest innovations to help improve the delivery of care.

The CPT Editorial Panel, appointed by the AMA Board of Trustees, is responsible for maintaining and updating the CPT code set. The CPT Editorial Panel is an independent group of expert volunteers representing various sectors of the health care industry. Their role is to ensure that code changes undergo evidence-based review and meet specific criteria.

The CPT Editorial Panel is supported by CPT Advisors, groups of physicians nominated by the national medical specialty societies represented in the AMA House of Delegates and the AMA Health Care Professionals Advisory Committee (HCPAC). As clinical experts in their fields, the primary role of CPT Advisors is to advise the CPT Editorial Panel on procedure coding and appropriate nomenclature by proposing revision to the code set, working with industry stakeholders as they consider additions and changes to CPT, and in educating their membership on the use and benefits of CPT codes.

The CPT Editorial Panel meets three times a year to review the applications for either new codes or revisions to existing codes. Anyone who wishes to participate can submit an application to attend a Panel meeting.

As medicine evolves with clinical innovations such as genomic testing and remote patient monitoring, physicians, innovators and any other stakeholder working within the health care space will need to assess whether a new or updated CPT code is needed to describe their innovation.

Data drives our health care system with medical innovation to improve patient care. The CPT code set stands primed and ready to grow and change with input from stakeholders across the health care landscape.

CPT refers to a set of medical codes used by physicians, allied health professionals, nonphysician practitioners, hospitals, outpatient facilities, and laboratories to describe the procedures and services they perform.

In 1966, the American Medical Association (AMA) created CPT codes to standardize reporting of medical, surgical, and diagnostic services and procedures performed in inpatient and outpatient settings. Each CPT code represents a written description of a procedure or service, removing the subjective interpretation of precisely what was provided to the patient.

The AMA updates CPT nomenclature, or medical language, to reflect advances in medicine. Although the AMA owns the copyright to CPT, the AMA invites providers and organizations to participate in the ongoing maintenance of the code set, welcoming those who use it to suggest changes to codes and code descriptors.

A second exception to numerical code order involves evaluation and management (E/M) codes. As shown in the Category I code outline below, E/M codes are printed first in CPT code books, although they start with the number nine. The AMA chose this order because E/M services are the most often reported healthcare services. This arrangement, as with resequenced codes, is designed for coding efficiency.

Category II codes, consisting of four numbers and the letter F, are supplemental tracking and performance measurement codes that providers can assign in addition to Category I codes. Unlike Category I codes, Category II codes aren't linked to reimbursement.

Category III codes, depicted with four numbers and the letter T, typically follow Category II codes in the code book. Category III codes are temporary codes that represent new technologies, services, and procedures.

What's more, this knowledge of anatomy and medical terminology must be thorough, as providers can perform services calling for CPT codes from any section in the code book. The codes a provider can report aren't limited by the specialty in which they practice. For example, X-ray codes are listed under radiology, but a primary care coder will be required to assign an appropriate X-ray code if the primary care physician interprets an X-ray.

EEqually important, before taking a coding position with the responsibility of determining and reporting CPT codes on medical claims, medical coders should consider seeking proper training and credentialing. This is the best way to ensure coding accuracy and optimal reimbursement for employers.

A CPT modifier consists of two numbers, two letters, or a number and a letter. Many situations require a coder to append modifiers to a CPT code to further describe the service or procedure provided. For example, some modifiers show that a procedure was performed on the right side of the body, versus the left side or both sides. Other modifiers indicate that a physician took extra time and effort to perform a service or procedure.

When someone refers to HCPCS (pronounced "hick-picks"), they most likely are referring to the HCPCS Level II code set. HCPCS Level I is the CPT code set. The main takeaway is that HCPCS Level II begins where CPT ends.

The Centers for Medicare & Medicaid Services (CMS) wanted a classification system for medical supplies, equipment, medications, and services not included in CPT, so around 1980 the AMA worked with CMS to develop a new set of codes.

Examples of services, supplies, and items with HCPCS Level II codes include orthotic and prosthetic procedures, hearing and vision services, ambulance services, medical and surgical supplies, drugs, nutrition therapy, and durable medical equipment.

An example of a diagnosis and service meeting medical necessity is when a patient comes into a medical office complaining of stomach pain, and the physician conducts a physical examination. The stomach pain (diagnosis) justifies the reason for the examination (service).

For quick access to a list of CPT codes and descriptions, working medical coders typically use software with procedure code lookup, though these tools are also available to students. The key to coding success is staying current and always referencing the code sets that apply to the date of service.

Current Procedural Terminology (CPT) is a medical code set that enables physicians and other healthcare providers to describe and report the medical, surgical, and diagnostic procedures and services they perform to government and private payers, researchers and other interested parties. CPT codes provide a common language to communicate these procedures and services for various purposes, including administrative management, billing, claims processing, medical care review and medical reporting.

The largest body of CPT codes, Category I covers procedures, services and contemporary medical practices that are widely performed. These five-digit numeric codes identify a procedure or service and range from 00100--99499. Many codes are ordered into subcategories based on procedure/service type. A descriptor nomenclature is also included.

Similar codes are clustered in a sequence. However, the sequence may be broken when a new code is added to a family of codes but a sequential number is unavailable, and in the case of evaluation and management (E/M) codes. Category I codes are widely accepted by a range of entities, including third-party payers and the U.S. Food and Drug Administration (FDA). New codes are released annually.

Category II CPT codes are supplementary tracking codes that are used for performance measurement. These codes are intended to facilitate data collection about patient health outcomes and the quality of care delivered. Using these codes is optional and is not a substitute for Category I codes.

The Category III CPT are temporary tracking codes that cover the latest technologies, services and procedures. These codes follow Category II codes in the CPT codebook. Unlike Category I codes, Category III codes identify services that might not be widely performed by healthcare professionals, might not have FDA approval, or might not have proven clinical efficacy.

Each Category III code consists of five digits, with four numbers and ending with the letter T. The purpose of these codes is to help researchers track new technologies and services that do not meet the criteria for a Category I code. A service or procedure with a Category III code may be reassigned a Category I code when it receives FDA approval or if evidence is available to prove either that it is performed by many providers, or it has proved effective.

CPT codes, or procedural codes, describe what kind of procedure a patient received while ICD codes, or diagnostic codes, describe any diseases, illnesses or injuries a patient might have. Physicians use CPT for billing. In contrast, hospitals used ICD-9-CM for billing, at least until, Sept. 30, 2015. Healthcare providers -- including hospitals and physicians -- also used ICD-9-CM codes to document the reasons for providing a certain service. On Oct. 1, 2015, data submitted to CMS transitioned from ICD-9- CM to ICD-10-CM/PCS.

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