What is CPT ?

The Current Procedural Terminology (CPT) code set is a procedural code set developed by the American Medical Association (AMA). It is maintained by the CPT Editorial Panel.[1] The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. New editions are released each October,[2] with CPT 2021 being in use since October 2021. It is available in both a standard edition and a professional edition.[3][4]

CPT coding is similar to ICD-10-CM coding, except that it identifies the services rendered, rather than the diagnosis on the claim. Whilst the ICD-10-PCS codes also contains procedure codes, those are only used in the inpatient setting.[5]

CPT is identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Healthcare Common Procedure Coding System. Although its use has become federally regulated, the CPT’s copyright has not entered the public domain. Users of the CPT code set must pay license fees to the AMA.

Types of code

There are three types of CPT code: Category I, Category II, and Category III.[6]

Category I

Category I CPT Code(s). There are six main sections:[7]

Medicare specific codes (HCPCS) for Preventive evaluation and management
Codes for evaluation and management: 99201–99499
Further information: Evaluation and Management Coding
Codes for anesthesia: 00100–01999; 99100–99150
Codes for surgery: 10000–69990
Codes for radiology: 70000–79999
Codes for pathology and laboratory: 80000–89398
Codes for medicine: 90281–99099; 99151–99199; 99500–99607
Category II

CPT II codes describe clinical components usually included in evaluation and management of clinical services and are not associated with any relative value. Category II codes are reviewed by the Performance Measures Advisory Group (PMAG), an advisory body to the CPT Editorial Panel and the CPT/HCPAC Advisory Committee. The PMAG is composed of performance measurement experts representing the Agency for Healthcare Research and Quality (AHRQ), the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA) and the Physician Consortium for Performance Improvement. The PMAG may seek additional expertise and/or input from other national health care organizations, as necessary, for the development of Category II codes. These may include national medical specialty societies, other national health care professional associations, accrediting bodies and federal regulatory agencies.

Category II codes make use of an alphabetical character as the 5th character in the string (i.e., 4 digits followed by the letter F). These digits are not intended to reflect the placement of the code in the regular (Category I) part of the CPT codebook. Appendix H in CPT section contains information about performance measurement exclusion of modifiers, measures, and the measures’ source(s). Currently there are 11 Category II codes. They are:

  • (0001F–0015F) Composite measures
  • (0500F–0584F) Patient management
  • (1000F–1505F) Patient history
  • (2000F–2060F) Physical examination
  • (3006F–3776F) Diagnostic/screening processes or results
  • (4000F–4563F) Therapeutic, preventive or other interventions
  • (5005F–5250F) Follow-up or other outcomes
  • (6005F–6150F) Patient safety
  • (7010F–7025F) Structural measures
  • (9001F–9007F) Non-measure claims-based reporting

CPT II codes are billed in the procedure code field, just as CPT Category I codes are billed. Because CPT II codes are not associated with any relative value, they are billed with a $0.00 billable charge amount.[10]

Category III
  • Category III CPT Code(s) – Emerging technology (Category III codes: 0016T-0207T[11])
Major psychotherapy and psychiatry revisions

The CPT code revisions in 2013 were part of a periodic five-year review of codes. Some psychotherapy codes changed numbers, for example 90806 changed to 90834 for individual psychotherapy of a similar duration. Add-on codes were created for the complexity of communication about procedures. Family therapy and psychological testing codes were among those that were unchanged.[12]

CPT is a registered trademark of the American Medical Association, and its largest single source of income.[13] The AMA holds the copyright for the CPT coding system.[14] However, in Practice Management v. American Medical Association[15] the U.S. Court of Appeals for the Ninth Circuit held that while the AMA owned the copyright, it could not enjoin a competitor on the basis that the AMA had misused its copyright.[16] Practice Management had argued that the publication of the CPT into federal regulation invalidated the copyright; the general debate around copyright and regulation access was revived in 2012[17] by a petition motivated by an Administrative Conference of the United States recommendation.[18]

Despite the copyrighted nature of the CPT code sets, the use of the code is mandated by almost all health insurance payment and information systems, including the Centers for Medicare and Medicaid Services (CMS), and the data for the code sets appears in the Federal Register. It is necessary for most users of the CPT code (principally providers of services) to pay license fees for access to the code.[19]

In the past, AMA offered a limited search of the CPT manual for personal, non-commercial use on its web site.[20] CPT codes can be looked up on the AAPC (American Academy of Professional Coders) website.[21]

History

As the AMA decided in April 1960, the Current Medical Terminology (CMT) handbook was first published in June 1962 – 1963 to standardize terminology of the Standard Nomenclature of Diseases and Operations (SNDO) and International Classification of Diseases (ICD), and for the analysis of patient records, and was aided by an IBM computer.[22] Procedural information was dropped in the transition from the SNDO to CMT, but was released separately as the Current Procedural Terminology in 1966.[23][24]

See also
References
  1. ^ AMA (CPT) CPT Process Archived May 11, 2016, at the Wayback Machine
  2. ^ Laura Southard Durham (1 June 2008). Lippincott Williams and Wilkins’ Administrative Medical Assisting. Lippincott Williams and Wilkins. pp. 2–. ISBN 978-0-7817-9789-4. Retrieved 26 May 2011.
  3. ^ Michelle Abraham; Jay T. Ahlman; Angela J. Boudreau; Judy L. Connelly; Desiree D. Evans; Rejina L Glenn (30 October 2010). CPT 2011 Standard Edition. American Medical Association Press. ISBN 978-1-60359-216-1. Retrieved 26 May 2011.
  4. ^ American Medical Association; American Medical Association (COR); Michelle Abraham; Jay T. Ahlman; Angela J. Boudreau; Judy L. Connelly (30 October 2010). CPT 2011 Professional Edition. American Medical Association Press. ISBN 978-1-60359-217-8. Retrieved 26 May 2011.
  5. ^ Alexander, Sherri, Pharm.D. (1 November 2003). “Overview of inpatient coding” (PDF). American Journal of Health-System Pharmacy. 60 (21 Suppl 6): S11-4. doi:10.1093/ajhp/60.suppl_6.S11. PMID 14619128. Archived from the original (PDF) on 17 September 2012. Retrieved 30 April 2013.
  6. ^ “Criteria for CPT® Category I and Category III codes”. American Medical Association. Retrieved 22 September 2020.
  7. ^ Marie A. Moisio (8 April 2009). Medical Terminology for Insurance and Coding. Cengage Learning. pp. 80–. ISBN 978-1-4283-0426-0. Retrieved 26 May 2011.
  8. ^ “Anesthesia for Procedures on the Upper Abdomen”. Archived from the original on 2016-10-05. Retrieved 2016-10-04., Anesthesia for procedures on the upper abdomen
  9. ^ “Anesthesia for lower abdomen”.,Anesthesia for procedures on the lower abdomen
  10. ^ AMA coding manual
  11. ^ CPT 2010
  12. ^ Centore, Anthony. “The 2013 Psychotherapy Codes: An Overview for Psychologists”. American Psychological Association. Retrieved 7 August 2020.
  13. ^ Rosenthal, Elisabeth (2017-03-29). “Those Indecipherable Medical Bills? They’re One Reason Health Care Costs So Much”. The New York Times.
  14. ^ AMA (CPT) CPT Licensing Archived October 21, 2016, at the Wayback Machine
  15. ^ “Practice Management Info. v. American Medical Ass’n, 121 F. 3d 516 – Court of Appeals, 9th Circuit 1997”. 25 June 2015. Archived from the original on 2015-10-13. Retrieved 2021-05-06.
  16. ^ Pamela, Samuelson (2007). “Questioning Copyrights in Standards”. Boston College Law Review. 48 (1).
  17. ^ Contreras, Jorge (2013-04-10), Technical Standards and Bioinformatics, vol. BIOINFORMATICS LAW, SSRN 2313788
  18. ^ “Administrative Conference Recommendation 2011-5 Incorporation by Reference Adopted December 8, 2011” (PDF). Administrative Conference of the United States. Archived (PDF) from the original on 2018-05-31. Retrieved 2018-05-31.
  19. ^ “Archived copy” (PDF). Archived from the original (PDF) on 2010-07-03. Retrieved 2010-12-22.
  20. ^ AMA (2012). “cpt® Code/Relative Value Search”. Retrieved from “CodeManager: Standard | CPT® Code/Relative Value Search”. Archived from the original on 2016-03-26. Retrieved 2011-07-06..
  21. ^ “CPT Codes Lookup”. Retrieved 2022-09-14.
  22. ^ “AMA to Publish Handbook of Medical Terminology”. Journal of the Mississippi State Medical Association: 16–17. April 1962.
  23. ^ Moriyama, IM; Loy, RM; Robb-Smith, AHT (2011). Rosenberg, HM; Hoyert, DL (eds.). History of the statistical classification of diseases and causes of death (PDF). Hyattsville, MD: National Center for Health Statistics. p. 7.
  24. ^ Borman, Karen R (2016). “Medical Coding in the United States: Introduction and Historical Overview”. In Savarise, Mark; Senkowski, Christopher (eds.). Principles of Coding and Reimbursement for Surgeons. Springer. p. 4. ISBN 9783319435954.