Overview of CPT Codes in Medical Billing

Whenever you have a medical procedure performed or health care service provided, it is coded in your medical record for tracking and billing. CPT codes and HCPCS codes are related systems of medical coding required for providers and insurers to send information electronically. See how they are used and what they mean for your health care.

CPT (Common Procedural Technology) codes are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical, and diagnostic services. They are used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer for that service. Since everyone uses the same codes to mean the same thing, they ensure uniformity.

A CPT code looks like a five-digit numeric code with no decimal marks, although some have four number and one letter. Some are used frequently like 99213 or 99214 (for general check-ups).

CPT codes are developed, maintained and copyrighted by the AMA (American Medical Association). As the practice of health care changes, new codes are developed for new services, current codes may be revised, and old, unused codes are discarded. Thousands of codes are in use and they are updated annually.

Uniformity in understanding what the service is and the amount different practitioners get reimbursed will not necessarily be the same. That is determined by the contracts between individual providers and insurers. For example, Doctor A may perform a physical check-up (99396) and be reimbursed $100 by your insurance company. If you went to Doctor B, his reimbursement by your insurance company for that same checkup, Code 99396, might only be $90.

HCPCS stands for Healthcare Common Procedure Coding System. They are codes used and maintained by the Centers for Medicare & Medicaid Services and are used to bill Medicare, Medicaid, and many other third-party payers. If you use Medicare, you'll see HCPCS codes in your paperwork.

There are two levels of codes. Level I codes are based on CPT codes (they are basically identical) and used for services and procedures usually provided by physicians. Level II codes cover health care services and procedures that aren't provided by physicians. Examples of items billed with level II codes are medical equipment, supplies, and ambulance services. HCPCS level II codes start with a letter and have four numbers. They can have modifiers that are either two letters or a letter and a number.

• 99214 may be used for an office visit
• 99397 may be used for a preventive exam if you are over 65
• 90658 indicates a flu shot
• 90716 may be used for chicken pox vaccine (varicella)
• 12002 may be used to stitch up a one-inch cut on a patient's arm

Some CPT codes are bundled. That is, they are used in combination with each other so they actually describe a number of aspects of care.

Your interest in these codes is usually related to your doctors' and insurance billings. HCPCS level II codes can be found online, but the level I codes and CPT codes are copyrighted by the AMA. The AMA charges license fees for use of CPT codes and access to the full listings, which means you won't find a comprehensive list online for free. To make them more accessible to patients, the AMA provides a means for looking up the individual CPT codes you might find on your doctor's bills or EOBs (estimates of benefits).

If you have paperwork that has a CPT or HCPCS code on it, and you want to figure out what that code represents, you can do so in a number of ways:

• Do a CPT code search on the American Medical Association website. You will have to register (for free) and you are limited to five searches per day. This allows patients to search for a CPT code or use a keyword to see what the associated CPT code might be.
• Contact your doctor's office and ask them to help you match CPT codes and services.
• Contact your payer's billing personnel and ask them to help you.
• Remember that some codes may be bundled but can be looked up in the same way.
• HCPCS level II code lists can be found on the CMS website and by performing a web search for more user-friendly sites.

CPT and HCPCS codes are found and used in various paperwork and documentation as you transition through any healthcare experience. Codes can be used to determine everything from your diagnosis to the cost of your healthcare.

• As you leave a doctor's appointment or are discharged from a hospital or other medical facility, you are given paperwork that includes a numeric summary of the services they provided to you. The five character codes are usually CPT codes or HCPCS codes (if you use Medicare). There are other codes on that paperwork, too. Some may be ICD codes, which may have numbers or letters and usually have decimal points.
• When you receive a bill from the doctor, before or after it has been sent to your payer (insurance or Medicare), it will have a list of services. Next to each service will be a 5-digit code. That's the CPT code or HCPCS code.​
• When you receive an EOB, Explanation of Benefits, from your payer (insurance, Medicare or others), it will show how much of each service was paid for on our behalf. Like the doctor's bill, each service will be aligned with its CPT or HCPCS code.

• CPT and HCPCS codes directly affect a provider's income. As such, they are very particular about how coding is done and usually employ professional medical coders or coding services to ensure procedures are coded correctly.
• Your doctor's office will usually start the coding process. If they use paper encounter forms, they will note on it which CPT codes apply to your visit. If they use an electronic medical record during your visit, it will be noted in that system.
• After you leave the doctor's office, your records are examined by medical coders and billers to assign the correct codes. Your records then go to billing to submit a list of the services you were provided to your insurer or payer. Doctors and facilities generally use electronic means to store and transfer this information, although some may still be done by mail or fax.
• Your health plan or payer such as Medicare then use the codes to process the claim and determine out how much to reimburse your doctor.
• State and federal government analysts use data from coding to track trends in medical care and to determine their budget for Medicare and Medicaid.

Being an informed patient is part of ensuring you receive the best medical care. When you see something you don't understand in your medical record or bill, discuss it with your healthcare provider or insurer. You have a right to take an active role in ensuring your health care is accurately tracked.