Question

Different sections of the CPT manual use different methods of organizing the information they contain. Some have major subdivisions based on anatomical site; others base their divisions on procedures. List the sections of the CPT manual and the method that is used in that section to organize the information. Discuss the reasons why different methods make sense, given the nature of the information represented in the different sections of the CPT. What are two examples to illustrate your thinking?

Answer 1

Current Procedural Terminology, or CPT is expansive, important code set published and maintained by the American Medical Association (AMA), and it is, with ICD, one of the most important code sets for medical coders to become familiar with.

CPT codes are used to describe tests, surgeries, evaluations, and any other medical procedure performed by a healthcare provider on a patient. This code set is extremely large, and includes the codes for thousands upon thousands of medical procedures.

CPT codes are an integral part of the billing process. CPT codes tell the insurance payer what procedures the healthcare provider would like to be reimbursed for. As such, CPT codes work in tandem with ICD codes to create a full picture of the medical process for the payer. “This patient arrived with these symptoms (as represented by the ICD code) and we performed these procedures.

CPT codes are also used to track important health data and measure performance and efficiency. Government agencies can use CPT codes to track the prevalence and value of certain procedures, and hospitals may use CPT codes to evaluate the efficiency and abilities of individuals or divisions within their facility.

Each CPT code is five characters long, and may be numeric or alphanumeric, depending on which category the CPT code is in.

With CPT, ‘Category’ refers to the division of the code set. CPT codes are divided into three Categories. Category I is the most common and widely used set of codes within CPT. It describes most of the procedures performed by healthcare providers in inpatient and outpatient offices and hospitals. Category II codes are supplemental tracking codes used primarily for performance management. Category III codes are temporary codes that describe emerging and experimental technologies, services, and procedures.

Note that while CPT codes have five digits, there are not 99,000-plus codes. CPT is designed for flexibility and revision, and so there is often a lot of “space” between codes.

CATEGORY1:

Category I CPT codes are divided into six large sections based on which field of health care they directly pertain to. The six sections of the CPT codebook are, in order:

• Evaluation and Management
• Anesthesiology
• Surgery
• Radiology
• Pathology and Laboratory
• Medicine

CPT codes are, for the most part, grouped numerically. The codes for surgery, for example, are 10021 through 69990. These codes are listed in mostly numerical order, except for the codes for Evaluation and Management. These Evaluation and Management, or E&M, codes are listed at the front of the codebook for ease of access

Here’s a quick look at the sections of Category I CPT codes, as arranged by their numerical range.

• Evaluation and Management: 99201 – 99499
• Anesthesia: 00100 – 01999; 99100 – 99140
• Surgery: 10021 – 69990
• Radiology: 70010 – 79999
• Pathology and Laboratory: 80047 – 89398
• Medicine: 90281 – 99199; 99500 – 99607

Within each of these code fields, there are subfields that correspond to how that topic—say, Anesthesia—applies to a particular field of healthcare. For instance, the Surgery section, which is by far the largest, is organized by what part of the human body the surgery would be performed on.

Each of these fields has its own particular guidelines when it comes to use. For example, the Surgery section has a guideline for how to report extra materials used (such as sterile trays or drugs) and how to report follow-up care in the case of surgical procedures.

CATEGORY II:

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.

Here’s a quick example. If a doctor records a patient’s Body Mass Index (BMI) during a routine checkup, we could use Category II code 3008F, “Body Mass Index (BMI), documented.”

These codes never replace Category I or Category III codes, and instead simply provide extra information. They are divided into numerical fields, each of which corresponds with a certain element of patient care.

Composite codes

• These codes combine a number of procedures that typically occur in conjunction with one main procedure.
  • Example: 0001F: heart failure assessed (includes all of the following):
    • Blood pressure measured
    • Level of activity assessed
    • Clinical symptoms of volume overload assessed
    • Weight recorded
    • Clinical signs of volume overload assessed
• Patient Management
  • Includes patient care provided for specific clinical purposes like pre- and postnatal care.
    • Example: 0503F: Postpartum care visit
• Patient History
  • Describes measures for select elements of patient history or symptom review
    • Example: 1030F: Pneumococcus immunization status assessed
• Physical Examination
  • Example: 2014F: Mental status assessed
• Diagnostic/Screening Processes or Results
  • Includes results of tests ordered, including clinical lab tests and radiological procedures
    • Example: 3006F: Chest X-ray documented and reviewed
• Therapeutic, Preventive, or Other Interventions
  • Describes pharmacologic, procedural or behavioral therapies
    • Example: 4037F: influenza immunization ordered or administered
• Follow-up or Other Outcomes
  • These codes describe the review and communication of test results to a patient, patient satisfaction, patient functional status, and patient morbidity or mortality
    • Example: 5005F: patient counseled on self-examination for new or changing moles
• Patient Safety
  • Includes codes that describe patient safety precautions
    • Example: 6015F: Patient receiving or eligible to receive foods, fluids, or medication by mouth
• Structural Measures
  • This short section includes codes that describe the setting of the delivered care, and also covers the capabilities of the healthcare provider
    • Example: 7025F: patient information entered into a reminder system with a target due date for the next mammogram

There are not nearly as many Category II CPT codes as there are in Category I, and in general you will not use Category II nearly as much. 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.

CATEGORY III:

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. There are codes in Category I for unlisted procedures, but if the procedure, technology, or service is listed in Category III, you are required to use the Category III 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.

Think of Category III as codes that may become Category I codes, or that just don’t fit in with Category I. Category I codes must be approved by the CPT Editorial Panel. 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. Due to the nature of emerging medical technology and procedures, it’s not always possible for an experimental procedure to meet these criteria, and thus become a Category I code.

Whether a Category III code becomes a Category I code or not, all Category III codes are archived in the CPT manual for five years. If at the end of this five year period the code has not been converted to Category I, this procedure must be marked with a Category I “unspecified procedure” code. When flipping through the Category III section of the CPT manual, you’ll notice that each of the codes has a phrase listing its sunset date below the code. Think of the sunset dates as expiration dates on the code.

Like Category II, these codes are five characters long, and are comprised of four digits and a terminal letter. In this case, the last letter of Category III codes is T. For example, the code for the fistulization of sclera for glaucoma, through ciliary body is 0123T.

Now that you have a better idea of what CPT looks like, how it’s formatted, and when to use which category of codes, let’s dive a little deeper into modifiers and how CPT codes look in action.