PROCEDURE CODING

Healthcare Common Procedure Coding System

CPT-4 is a component of the HCPCS (Health Care Procedural Coding System). HCPCS codes were created by the AMA, and are maintained and renewed on a yearly basis by the AMA with the guidance of an editorial panel and advisory committee. The CPT (Current Procedural Terminology) Book is a standardized code set used to describe the medical, surgical and diagnostic services and procedures provided by physicians and other healthcare providers.

CPT codes are divided into three categories. Category I codes describe procedures which are accepted as standards of care codes and are also the primary codes used for reimbursement for physician and non-physician provider services from thirdparty payers and patients. Category II codes are used for performance measures and data collection. Category III codes are temporary codesfor emerging technologies, services and procedures.

According to the general instructions for use of the CPT book, any procedures or services in any section of the book may be used to designate the services rendered by any qualified physician or healthcare professional. CPT does not determine the reimbursement for services. This amount is determined by contracts between the healthcare providers and the insurance carriers that cover the provider’s patient population. The CPT guidelines also indicate that any service or procedure performed should be documented in the patient’s medical record to support the code(s) chosen. If a service or procedure provided by the physician or other healthcare provider is not described in the CPT book, the unlisted procedure code for the appropriate section should be chosen.

TheCategory ICPTcodes are divided into six sections. Each section is further divided into subsections. Each section and subsection has instructions on the appropriate use of the codes. The codes in Category I are listed in numeric order with the exception of the evaluation and management codes (99201-99499), which are listed in the beginning of the book, because most physicians will use these codes in their practices.

The six sections of the CPT Category I codes are: 

• Evaluation and Management (E/M) 99201-99499 

• Anesthesiology 00100-01999 

• Surgery 10021-69999 

• Radiology 70000-79999 

• Pathology and Laboratory 80000-89356

• Medicine 90000-99602

In addition to the Category I codes, the CPT book includes Category II codes, Category III codes and several appendices. Appendix A provides a list of all modifiers and descriptions of the modifiers.