The CPT Codes Guide: Everything You Need to Know About Medical Billing Codes

Did you know that one of the first hospitals was built in the 4th century AD? Since then, healthcare has made leaps and bounds and is now a vital part of our lives. But the medical industry would be nothing without CPT codes. 

If you are new to the medical world, you might need to learn these codes and what they are for. That’s what this CPT codes guide will teach you. Once you know the basics concerning the types of CPT codes, it will be much easier to maneuver the medical industry.

It will make your life much easier, too. Keep reading, and you’ll learn all about medical billing codes and why they’re so important. 

What You Need to Know About CPT Codes

CPT stands for Current Procedural Terminology. Many people have no idea what these essential codes are, mainly because there is no need for the average person to know about them. 

They are usually handled by people at the back end of the medical billing process. But while most people don’t know these codes, they are essential to the medical industry’s work. When you first see these codes, you might need clarification on their meaning. 

They don’t look like much more than a short string of numbers. But these numbers carry significant meanings. Each series of numbers signifies a specific task that has to be completed or has already been completed.

A healthcare provider is typically the one that provides these codes. Almost everything in the medical field has corresponding medical billing codes. There is a code for a standard check-up, a code for diagnostic services, and so on. 

You can imagine that a list of CPT codes would be very long because of this. There are also many types of CPT codes to address the many different needs in the medical field. The goal of CPT codes is to track as much information as possible. 

Understanding the Basics

Many factors go into managing a medical practice. You have to keep up with the staff, the patients, the medical equipment, etc. You must also keep up with specific treatments, lab work, results, and other important information. 

If you don’t keep track of all these aspects, the entire medical field wouldn’t be anything more than a jumbled mess. However, CPT codes can solve this problem because they are one of the best methods for creating order in the medical field. 

Medical insurers also find these codes useful. This is because the codes make it easy to track patients’ billing information. Specific codes will reveal how much money should be paid for a particular service.

These codes are also ideal for reducing common mistakes in the medical industry. While errors still happen, they are much less common when CPT codes are used—this is essential for the medical billing process. 

Many people don’t realize that the billing process is just as important as the rest of the medical field. If patients can’t get through the billing process smoothly, they may not want to return for more treatment. This is also true if billing errors and other frustrations make people dislike the medical field.

But what kind of codes should you look out for? What should spring to mind when you see a specific code on a document? 

What Do CPT Codes Look Like?

Almost all CPT codes are five digits long. You will also come across the rare code that consists of four numbers and one letter. There will never be decimal points in these codes.

After you start seeing CPT codes enough times, you will realize that some are very common while others are not. An excellent example of this is the code 99213. 

This code represents a general office visit. The visit may consist of a patient with a health complaint or two. The visit may also be a follow-up appointment. 

You may also see the code 99214 used for general office visits. While many codes stay the same for decades, others may be updated yearly. While these updates can make CPT codes confusing, they also help ensure that this system is always modern and relevant. 

Some codes that are not used as often may get thrown out and abandoned for future use. New codes can also be created, but this is less common. New codes are usually only made if a new medical task or service needs to be addressed.

There are also certain limitations that you should know about regarding CPT codes. They are meant to give the vast majority of the healthcare field a shared recognition of specific medical tasks. However, this does not make CPT codes a universal language because the use of CPT codes may vary between different organizations. This also does not mean that CPT codes communicate the same amount of money.

How CPT Code Meanings Can Differ Between Providers

Some CPT codes may be used in medical billing to mean $50, $100, and so on. 

But some of those same codes may also signify a different amount of money. This is why many people need clarification on these codes, especially when working with different providers. One provider’s and another provider’s codes may look the same, but they may mean other things. 

A CPT code is not a contract. To understand how much money a provider will get paid, it is necessary to look at a contract from an insurer. CPT codes act as a safety net to help make sure that providers are getting paid the proper amount. 

Suppose you need a physical check-up from your doctor. The code for this check-up is 99396. Because you chose this particular provider, that code may translate to $100, which your insurance company will use to pay your doctor. 

But what if you were to get the same check-up from another provider? The code would still be the same (99396). But based on their contract with that provider, the insurance company may decide that only $90 should get paid to your doctor. 

Why might this be? These changes are in the hands of health insurance companies. The creators of CPT codes don’t have much to do with it. 

Understanding Different CPT Code Categories

Because there are so many different CPT codes, it wouldn’t make sense to jumble them all together. This would confuse them, defeating their purpose, so CPT codes are organized into categories instead. 

It is important to remember these categories and why they’re essential. It might help if you ever have to deal with medical billing codes. There are three main categories, which are labeled as follows:

• Category I
• Category II
• Category III

There is also a fourth category called PLA codes. Category I contains some of the most common billing codes. These include codes for procedures like check-ups, physicals, exams, and certain treatments. 

It also includes codes for devices. These may include surgical tools, medical devices, lab equipment, etc. This category also contains codes for drugs. 

These drugs may include a variety of medications as well as vaccines. The codes in this category range from 00100 to 99499. This extensive range is then broken down into subcategories to make the codes easier to find and identify. 

The subcategories are based on what part of the body is being treated, but they may also be based on the required procedure. The majority of medical billing codes fall into Category I. 

The next most common codes are in Category II. This category primarily regards performance measures for the patient, which may involve a follow-up or continued treatment. 

Quality of care services are also included in this category. This category is necessary for making sure that patients feel cared for. This category consists of alphanumeric tracking codes.

The Importance of Coding Categories

While these codes are important, they are often considered supplemental or optional. Some healthcare providers won’t use them because they are deemed unnecessary billing codes. 

While they are not always necessary, they can still help ensure everything is organized as it should be. Category III codes are not very common either, but they can still be helpful in particular situations. 

They are alphanumeric codes—often used for new medical technology or services. Suppose a medical professional is starting to use emerging technology in their services. Because this technology is unexplored, it would make sense to use a new code to address it. 

Category III codes are almost always temporary. The new procedure will either stop being used, or a new and more permanent code will be created. The point of these codes is to collect data about new medical procedures or services.

They are also sometimes used for payment, but this is rare. Once a Category III code is created, it must get added to Category I within five years. If it isn’t, then it must get deleted from the system. 

PLA (Proprietary Laboratory Analyses) codes are relatively new to the world of CPT. They are specifically for lab testing. Single labs usually provide the codes, though multiple labs may also use them. 

You will often find Clinical Diagnostic Laboratory Tests (CDLTs) codes in this category. You may also see codes for Advanced Diagnostic Laboratory Tests (ADLTs). 

How Are CPT Codes Maintained and Updated?

CPT is a primary medical language that has been around for more than 50 years. The point is to make it much easier for people, especially those in billing departments, to communicate specific messages to each other. These messages may include detailed analytics, payment information, and so on. 

CPT codes have mostly stayed the same over the decades. They need to be simple to be easily understood and transmitted. But this does not mean that they have stayed the same. 

As with anything in the medical industry, it is necessary to maintain these codes over the years. If they were left untouched, many of the codes would become obsolete. Many medical services have stopped being performed over the years. 

Many new services have popped up and required new CPT codes to be created. But who is in charge of maintaining and updating all these codes? The CPT Editorial Panel is the main power behind this system.

The Panel gets continuous updates from various clinical professionals throughout the healthcare industry. The Editorial Panel communicates with these experts and learns about the current quality of available care.

It also explores new services, discontinued services, and so on. 

The members of the Editorial Panel are appointed by another organization: the AMA Board of Trustees.

Understanding the CPT Editorial Panel

The people who work on the Editorial Panel are not employees but rather volunteers. 

These volunteers are some of the most talented experts in the medical industry. They all work independently and combine their knowledge of different healthcare sectors, allowing them to create a more well-rounded system for CPT codes.

Any code changes must go through a review based on related evidence. The CPT Editorial Panel members are responsible for ensuring that these reviews are conducted properly. They also need to confirm that any changed codes meet relevant criteria—ensuring they are as high-quality as possible. 

Despite all this, the CPT Editorial Panel would not be able to exist without the help and support of CPT Advisors. These advisors are physicians who are nominated by healthcare societies throughout the US. 

The AMA Health Care Professionals Advisory Committee (HCPAC) is one of the most prominent societies. These physicians are also represented by the AMA House of Delegates.

A certain amount of prestige in the medical field is necessary to be part of these societies. It can be inferred that these doctors are very qualified because creating and maintaining CPT codes is a very delicate job.

The Role of CPT Advisors

The CPT Editorial Panel can’t do much until the CPT Advisors give them instructions. These advisors guarantee that all CPT codes follow a particular system and are classified correctly. 

They are also in charge of communicating with other important healthcare industry members. They aim to ensure that CPT codes are changed, added, or removed when necessary. They may sometimes work with medical stakeholders to ensure the relevant CPT codes function as they should.

The advisors may also occasionally have more casual meetings about the general benefits of these codes. The CPT Editorial Panel has three sessions every year. Each gathering provides the opportunity to review new CPT codes. 

It is also an excellent time to review older codes that may need to be revised or removed. It is also possible for people who are not on the Editorial Panel to participate. However, these individuals must submit an application to get approved. 

Why Are CPT Codes So Important?

CPT codes don’t only document specific medical procedures and services. They are also helpful for determining how much a patient should pay for the services they receive. The code will also determine how much the patient’s health insurance will pay their healthcare provider.

Making sure that services are coded correctly is no laughing matter. Hospitals and other facilities are very serious about confirming that their patients are billed correctly because many problems can arise if not. 

Because hospitals are so concerned about using CPT codes correctly, they often hire professionals. These professionals are usually experienced medical coders with years of CPT knowledge, allowing them to use the most relevant codes for various services and procedures. 

It is possible to hire an individual coder and a coding service. A coding service may involve several coders working at once. This can speed coding tasks along and make them more efficient and accurate. 

One of the many reasons CPT codes are so important is that they have been used for a long time. Hospitals and clinics are so used to them that they would have difficulty functioning without them. This is also true of health insurance companies that rely on these codes to dispense the right amount of money to healthcare providers.

Why CPT Codes Are Necessary

If CPT codes were misused, the healthcare system would fall apart. It would be complicated to document and bill for various health services. It would also take a lot of work to determine how much a particular medical service would cost a patient. 

The patient would then have to deal with the stress of figuring out how much their insurance company owes their provider. The provider would also be stressed about needing to know the correct amount owed. 

All this could result in a delay in reimbursement, which may cause even more problems. The good news is that CPT errors don’t happen often because medical billing teams are very good at what they do. 

They work with the utmost care to confirm that every number and letter is correct. They also double-check the codes to ensure they are coding for exemplary service. Ensuring medical billing codes work correctly is also crucial for the hospital’s or clinic’s reputation. 

If a clinic has a reputation for having a lot of coding errors, patients might want to avoid going to that clinic. They may not want to deal with the frustrations that the clinic has in store. They may instead go to another clinic where they won’t have to deal with these issues. 

This is a sure way for a hospital or clinic to lose business. But if the CPT codes are always done properly, there will be no need to lose patients over issues like these. 

How Are CPT Codes Used?

There are many different uses for CPT codes. The first step is the initial coding process—when a patient sets up an appointment, a code needs to be set up to describe what will happen during the appointment. 

It isn’t the patient’s responsibility to know about these codes, but rather the healthcare provider’s or office staff’s. Suppose a patient makes an appointment for an annual check-up. The office staff will note the particular CPT code that applies to that type of appointment.

Most clinics use an electronic health record (EHR), allowing office staff and healthcare providers to input information digitally. It is swift and efficient compared to traditional paper documents. 

However, some clinics still use paper documents. CPT codes are listed both on physical and digital forms. It is not often necessary for office staff or medical professionals to memorize any of these codes. 

There are thousands of them, so memorizing them would be impossible. These codes can instead be searched for using the name of the service they represent. After the patient leaves the clinic, it is time for the verification and submission stage. 

Experienced medical billers and coders can then look at the patient’s CPT codes. Their job is to make sure that each code is assigned to the correct service or procedure. 

Most codes are straightforward and only refer to one thing. However, some codes are known as “bundle” codes. This is when several procedures are grouped into one CPT code. 

The Progression of CPT Codes

Bundle codes are often used when several procedures are needed in one appointment. Suppose you get into a car accident, and your face is severely damaged. 

Once you get to the hospital, you may get an X-ray and discover you have a broken jaw. You may then go through surgery to correct that fracture. The X-ray and the surgery may be grouped into one CPT code rather than two.

Once the billing team sees the correct codes, they will submit this information to the patient’s insurance provider. They will also submit whatever services the patient receives at the clinic, which is done digitally. 

This ensures that the information gets to the insurance provider instantly. But you may occasionally find clinics and hospitals that fax this information or send it through the mail. Once this information is on its way, it will then be time for claims processing. 

This is when the patient’s health insurance company takes over. The company will process the claim depending on what kind of CPT codes they receive. The code will determine how much the company should pay the patient’s healthcare professional. 

The patient may then need to pay some out-of-pocket costs. The CPT codes will help determine this as well. Many insurance companies pay the majority of the costs. 

This ensures the patient doesn’t have to pay an arm and a leg to get basic healthcare. The final step in this process is research. The research stage is necessary for allowing the healthcare industry to evolve. 

Why CPT Coding Data Is Useful

Health insurance companies collect large swaths of CPT code data. They then analyze this data and see how certain services and prices change over the years—helping them make predictions about how healthcare prices and trends will change in the future.

Understanding future health costs is important both for insurance companies and patients. Medical costs have been increasing over the years. Insurance companies have continuously made changes to account for this issue. 

This ensures that patients can still afford the medical treatment they need to stay healthy. Government officials may sometimes collect and use CPT code data, allowing the government to better understand the healthcare industry’s current state and where it is headed. 

Tracking trends in the healthcare field is very common among various government bodies. The government then uses this information for Medicare and Medicaid. Proper government budgeting is necessary for these programs to function. 

The progression of CPT codes is very much like a series of interlocking chains; they are closely linked to different people and organizations. When combined, they create an important string of information regarding medical data and pricing. 

Where and When Will You See CPT Codes?

You’ll be hard-pressed to go even a day in the healthcare industry without seeing at least one CPT code. These codes are everywhere, and you will see them throughout the day in hospitals and clinics. Many documents require these codes in a list format, or they won’t be able to get processed. 

Patients are also exposed to their fair share of CPT codes. Suppose you are a patient and you’ve just been discharged from the hospital. Depending on what procedure you had done, you will get sent home with a variety of documents. 

You don’t have to look too closely to find CPT codes listed on these documents. Remember to look for a string of five numbers (or four numbers and a letter). Most patients look at the written description of what procedures they received on the document. 

But if you are familiar with common CPT codes, you may also be able to translate the codes on the documents. Once you find the CPT codes, you may notice other codes on the documents that don’t fit the CPT format. 

These are additional codes that provide further information. Common types of codes include ICD codes. These differ distinctly from CPT codes since they often contain decimal points and a blend of numbers and letters.

They play an essential role in healthcare reimbursement. It is often necessary for them to occur along with CPT codes.

Recognizing CPT Codes When They Show Up

A patient will be exposed to CPT codes again when they receive their medical bill in the mail. 

Similar to the original documentation, the bill will list the services that the patient received. It will also list these services in the CPT code format. The CPT codes are usually right next to the written services. 

This ensures that there is no mistaking which code goes with which service. You’re always free to double-check the codes by typing them into Google. You can then see if the codes align with the services you received. 

There should be no issues if the medical billers and coders did their jobs correctly. A patient may later receive an explanation of benefits (EOB) from their insurance company. This will give the patient a rundown of how much they paid for their medical services. 

Each service will be listed with its CPT code. Medical billers and coders naturally see CPT codes much more often than patients. They have to work with them all day and confirm they align with the services they’re meant to represent. 

They also need to ensure they align with what health insurance companies want and comply with the criteria set by the CPT Editorial Panel. This requires them to have a significant amount of attention to detail. 

The Consequences of Making a Coding Mistake

Patients could get very angry if there is even a tiny coding mistake. A patient might be surprised to see that they have been atrociously overcharged for an annual check-up because the CPT code was wrong. The code might have gotten listed for a much more expensive procedure, which can cause a lot of stress on behalf of the patient. They’ll also need to go out of their way to make phone calls and confirm that this problem is resolved. If these problems happen constantly, patients may be reluctant to return to that medical facility. 

This can harm the healthcare facility’s business and the patient’s health. But if the codes are correct in the first place, there will be no need to worry about this problem. There are many ways to prevent CPT code mistakes. 

The first way is to pay more attention. If coders daydream while they code, they will be far more likely to make mistakes. This happens more often than it should, and it can slow the whole process down. 

Double-checking the codes is also important. Since these codes consist mostly of numbers, they can seem very uninteresting. This may spur a coder to refrain from checking their work. 

But this is how mistakes happen. Double-checking the codes will ensure that they align with the services they’re supposed to represent. 

Should You Get a Medical Billing and Consulting Service to Help?

Because medical CPT coding is such a delicate task, you should delegate it only to people you trust. Some people are reluctant to hire professionals because they may want to do most of the billing and coding themselves. 

But this could backfire on you if you don’t know what you’re doing. Medical professionals are often very busy and don’t have time for coding. To bill and code correctly, they need more time to double-check the codes and take their time to ensure they’re correct. 

Because they’re often in a rush, they are more likely to make mistakes when using CPT codes. This is the last thing you want to happen if you’re trying to take care of your patients. You don’t want to treat them and send them home with incorrect documents and bills. 

Some people may not want to hire medical billing professionals to save money. But you will lose money in the form of patients if CPT coding errors are a regular issue.

The Importance of Medical Billing and Consulting Services

Once patients see that a healthcare facility isn’t reliable, they will go elsewhere for their medical needs. 

This is why it’s worth it to spend a bit of money to hire medical billing professionals—allowing the professionals to do all the heavy lifting while you focus on more important things. Medical consulting services are also essential. 

They can tell you what you might be doing wrong and how you can improve your services. Many medical professionals make mistakes left and right without realizing it. This is no way to work in the medical field or provide quality healthcare to your patients. 

These consultants can discuss your most prominent issues and explain why they might be harming the way you work. They can also offer various solutions, ensuring that you will quickly improve your place in the medical field. 

These services know a lot about medical billing and coding—allowing them to target your coding needs and show you the path you can take to improve. This can reduce stress for both you and your patients. 

It will also make your work much more straightforward. 

How to Choose the Right Service to Manage Your Medical Billing

Hiring a professional to manage your medical billing might sound great to you. But you can’t pursue this interest until you find the right billing service to hire. There are many services out there, and you mustn’t choose one at random. 

If you do that, there’s a good chance that the service won’t get optimized for your unique needs. As a result, it might not help you very much, and you will have wasted your money. It is a much better idea to do your research and consider your options before you make a final decision. 

Make sure you choose a service with plenty of CPT experience. CPT coding has been around for over 50 years, so the more years of experience a service has, the better. They will know about the most common coding mistakes and how to avoid them. 

They will also know how to streamline the coding and billing process, allowing you to focus more on your patients than ever before. You should also scan the internet for customer reviews. 

Customer reviews tell you a lot about the quality of a medical billing and consulting service. You should run the other way if you find a service with primarily negative reviews because that service won’t have your best interests at heart. 

But if you find a service with many positive reviews, you’ll be in luck. This service cares about making its customers happy and ensures that the money you spend to hire them will be worth it. 

Your Ultimate CPT Codes Guide

Any CPT codes guide will emphasize the importance of using the correct codes, and this one is no different.

CPT codes need to be precise to document specific medical services and treatments. They are important for patients, medical professionals, and health insurance companies. 

A medical billing service can guarantee that all your CPT codes are written properly. They can also keep you from doing all the heavy lifting, giving you more time and energy to do your job.

Are you ready to hire a professional? Check out our services and see how we can help.