CPT and HCPCS Codes

Basics for Medical Claims Processing

In order for medical claims to process correctly, there is a standard of codes used to identify services and procedures. This system of coding is called the Healthcare Common Procedure Coding System known as HCPCS and pronounced "hicks picks".

In addition to being used for accurate coding of treatment, medical claims must be billed in combination with codes for additional services performed in the office, the corresponding modifiers, if necessary, and ICD-9 or diagnosis codes.

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CPT/HCPCS Coding Overview

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HCPCS codes are regulated by HIPAA, which requires all healthcare organizations to use the standard codes for transactions involving healthcare information. HCPCS includes two levels of codes.

Level I consists of CPT codes. CPT or Current Procedural Terminology codes are made up of 5 digit numbers and managed by the American Medical Association (AMA). CPT codes are used to identify medical services and procedures ordered by physicians or other licensed professionals.

Level II of the HCPCS consists of ​alphanumeric codes consisting of one alphabetical letter followed by four numbers and are managed by The Centers for Medicare and Medicaid Services (CMS). These codes identify non-physician services such as ambulance services, durable medical equipment, and pharmacy.

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CPT Codes Breakdown

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00000-09999: Anesthesia Services

10000-19999: Integumentary System

20000-29999: Musculoskeletal System

30000-39999: Respiratory, Cardiovascular, Hemic, and Lymphatic System

40000-49999: Digestive System

50000-59999: Urinary, Male Genital, Female Genital, Maternity Care, and Delivery System

60000-69999: Endocrine, Nervous, Eye and Ocular Adnexa, Auditory System

70000-79999: Radiology Services

80000-89999: Pathology and Laboratory Services

90000-99999: Evaluation & Management Services

More

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HCPCS Codes Breakdown

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A Codes

  • Medical and surgical supplies
  • Transportation services
  • Diabetic shoes
  • Dressing
  • Radiopharmaceuticals

B Codes

  • Enteral and parenteral therapy
  • Supplies
  • Formulae
  • Nutritional solutions
  • Infusion Pumps

C Codes

  • Outpatient PPS
  • Drugs
  • Biologicals
  • Devices

D Codes

  • Dental Procedures

E Codes

  • Durable medical equipment

G Codes

  • Procedures/professional services

H Codes

  • Alcohol and drug abuse treatment services

J Codes

  • Drugs administered other than oral method

K Codes

  • Temporary Codes
  • Durable medical equipment

L Codes

  • Orthotic/prosthetic procedures
  • Orthopedic shoes
  • Prosthetic implants

P Codes

  • Pathology and laboratory services

Q Codes

  • Supplies used to make cast and splints

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Most Commonly Used Evaluation and Management Codes

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The most frequently used codes are medical Evaluation and Management (E/M) codes.

  1. 99201-05: New Patient Office Visit
  2. 99211-15: Established Patient Office Visit
  3. 99221-23: Initial Hospital Care for New or Established Patient
  4. 99231-23: Subsequent Hospital Care
  5. 99281-85: Emergency Department Visits
  6. 99241-45: Office Consultations

E/M services fall under two different patient types:

  1. New Patient: a new patient is identified as an individual that has not been treated by a physician or other healthcare professional of the same specialty in the same practice
  2. Established Patient: an established patient is identified as an individual that has been treated by a physician or other healthcare professional of the same specialty in the same practice

E/M services fall under four different categories:

  1. Office or outpatient setting
  2. Hospital inpatient
  3. Emergency department
  4. Nursing facility

E/M services are based on four different examination types:

  1. Problem focused
  2. Expanded problem focused
  3. Detailed
  4. Comprehensive

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CPT Code Revisions and Resources

CPT codes are issued by the American Medical Association and are under their copyright. They are constantly updating them, removing, revising, and adding codes. The major revision is published each October, with six-month updates for emerging technology and vaccines.

Medical coders and organizations buy the annual CPT Professional Edition from the AMA to use as their reference for the codes.  It is important for medical offices and organizations to have the current coding manual. Medical billing software companies pay a license fee to keep the codes updated in their systems.

Patients and other users can register on the AMA website and perform up to 12 searches of CPT codes.

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