CPT Codes; What are you Getting Billed for?


All of us visit some sort of medical office from time to time and some of us make the visit a routine. No matter how many times we go in for a checkup or treatment we usually end up paying a relatively inexpensive co-pay for the services rendered to us. So who makes up the difference and how do they pay it? Obviously, the doctors and nurses that we visit are not making a living off of our co-pay; so how do they obtain the additional money from our heath care provider? In this article, I will tell you the basic information about CPT Codes and what they are used for.

CPT Code background

Before CPT Codes existed and when ICD-9-CM codes were just being developed, doctors had to write out in words what symptoms a patient had, what the diagnosis most likely was, and what visits, services, and procedures they thought they should get paid for. Then in 1966 Current Procedural Terminology or CPT was designed by the American Medical Association to assist doctors in billing Medicare and health providers using codes. Doctors use the CPT Codes to specify to health care providers the service rendered so that they can get paid. Currently with 8,568 codes and descriptors available with the CPT 2005 Codes, it is easy to see why these codes can sometimes drive doctors crazy with regard to knowing which ones to use and for what. However, the general idea behind the codes was to help doctors and create a standard as to what Medicare and health providers will pay for.

Where do CPT Codes come from?

There is a panel of 17 members, called the CPT Editorial Panel, who meet 4 times every year to consider proposals for changes to the CPT Codes. The American Medical Association provides this staff which is responsible for editing, adding, and deleting CPT Codes. There is also a CPT Advisory Committee, made up of representative form over 90 medical societies and heath care organizations, which assist the Editorial Panel in its efforts to maintain the CPT Codes.

What are the CPT Code categories?

CPT Codes are classified into three categories. Category I are five digit codes that make up the main body of CPT Codes. When someone refers to CPT Codes, they are generally referring to category I. The codes found in category I represent procedures that are consistent with contemporary medical practice and are widely performed. Category I codes are then broken down into the following six sections.

1. Evaluation and Management

2. Anesthesiology

3. Surgery

4. Radiology

5. Pathology and Laboratory

6. Medicine

Category II CPT Codes are supplemental tracking codes that are used for performance measurement. They typically describe services that are included in an evaluation and management service. They are optional four digit codes followed by the letter “F” which should not be used as a substitute for category I codes.

Category III CPT Codes represent temporary codes for new and developing technologies. They were created to allow for data collection and tracking for new procedures and services. Category III codes are different from Category I CPT codes in that they identify services that may not be performed by many health care professionals. The hope behind these codes is to help researchers track developing technology and services to facilitate widespread use and clinical effectiveness. The Category III codes are four digits long followed by the letter “T”. These codes are intended to be temporary and will be abandoned if the procedure or service is not accepted as a Category I code within five years.

As you can see, CPT Codes are a valuable asset to the medical world. They create a unified system of coding that is accepted and used throughout the United States. These codes are modified and updated every year to account for the changes in the medical field. You now have a better knowledge of how your medical health provider is charged each and every time you have any medical work performed.


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