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Exploring The Intricacies Of Current Procedural Terminology

Every day in the United States, doctors and other health professionals diagnose and treat the illnesses of their patients. To promote accurate billing and accountability in the healthcare field, various health workers and medical coding specialists assign Current Procedural Terminology (CPT) codes to each surgical procedure, treatment or medication recommended for patients. CPT helps those within the healthcare community remove ambiguity from communications with colleagues, insurance companies and patients concerning health-related topics. CPT is a coded language designed to increase accuracy and uniformity in treating and charging for medical services.

Universal use of the codes among professionals in all the health disciplines also assists government agencies and researchers garner valuable statistical information on the extent of various health problems and the effectiveness of treatments. Pharmaceutical companies use the data to determine the effectiveness and production requirements for various drugs that doctors prescribe. Insurance companies benefit from CPT by having access to a convenient shorthand that describes the complexities of all forms of medical treatment in a way that laymen can understand and process.

CPT A Standard Way To Communicate Complex Information

doctor performing medical procedure

The modern medical profession is a diverse and overtly technical branch of the sciences. Medical scientists make new discoveries regularly, doctors and other knowledgeable health professionals develop new procedures for treating disease and injuries and drug companies design new medications to relieve suffering and reduce symptoms. CPT helps all parties involved by providing a standard way to describe the vast store banks of medical knowledge available.

A Brief History

In 1966, the Johnson Administration began implementing its “Great Society” programs. Part of this comprehensive government initiative included the introduction of Medicare and Medicaid. With the government now required to help cover some medical procedures, the need for a standardized way to itemize medical tasks arose to streamline the process and ensure its fairness.

nurse performing medical tests

The American Medical Association won out over several competing entities and implemented the CPT as the officially recognized method of coding medical claims for surgeries covered by Medicare and Medicaid. As the years passed, and many new medical processes arrived, CPT has expanded to meet the challenges. With extensive revisions occurring in the years 1970, 1977, 1983, 1986, 1987 and 1996, CPT today is the favored system for describing and reporting health care services by private and government insurers and providers.

The Oversight and Editing Process

The AMA CPT Editorial Panel manages updates and modifies the usage guidelines for the CPT codes. Physicians, leaders of healthcare associations, medical insurance experts and others sit on the panel and work together to determine the appropriate code determination of current and emerging medical treatments. The CPT Editorial Panel, assisted by the CPT Advisory Committee, reviews application submissions for new and revised codes and decides how and when to incorporate code changes.

lifeline

When a new application is received, the Editorial Panel must first ascertain whether the request for a code edit is new or if it the panel has examined it in the past. If the request is new, the CPT Advisory Committee begins a lengthy process of evaluating and commenting on the application. When the Advisory Committee finishes its review, it submits its findings to the Editorial Panel to make the final revisions official or to deny the request.

The Structure of the CPT Code Set

lung xray

To make the CPT code set a functional way to communicate healthcare information, the American Medical Association breaks the code into three separate categories pertaining to different functions. Each category can also be divided into different sections that focus on various aspects of a particular category’s purpose. Understanding the role of each CPT category is an essential first step in learning how to use the code

Category 1: Procedures and Contemporary Medical Practices

CPT Category 1 codes are the most common type. These five-digit numeric codes indicate healthcare services that are approved by the Food and Drug Administration (FDA). Category 1 codes all refer to conventional procedures that are currently in everyday use by doctors and health providers. CPT Category 1 codes can reside in any of six different sections.

  • Surgery  - Treating health conditions with incisions or manipulations using various instruments.
  • Radiology- Diagnosing and/or treating diseases with the use of high-energy radiation such as X-rays.
  • Anesthesiology - Using drugs to induce insensitivity to pain before surgical operations.
  • Pathology and laboratory - Examining human tissue samples to diagnose diseases.
  • Medicine - Providing patients with a prepared compound to treat or prevent diseases.
  • Evaluation and management - Diagnosing disease and determining proper medical treatment for a patient.

These broad areas incorporate much of what constitute modern health services. As a result, Category 1 CPT codes are by far the most common ones used.

Category 2: Clinical Laboratory Services

DNA strip

Category 2 codes help with measuring how effective treatments and medications are at improving patients’ conditions. Physical exams, diagnostic services and therapeutic measures are included in this category. These codes help health organizations to monitor critical areas of patient care continuously. By examining the data provided by Category 2 codes, health experts can spot significant trends and areas in medical treatment that need improvement.

Category 3: Emerging Technologies, Services and Procedures

surgeons doing medical procedure

The CPT Editorial Panel reserves the final CPT code category, Category 3, for new medical procedures and technologies. When a new medical service is in its initial stages of development, it typically is awaiting approval from the FDA. During this trial stage, it can be assigned a Category 3 CPT code so that its effectiveness as a treatment can be monitored. After reaching the level of FDA approval, it can be reassigned as a Category 1 service.

CPT Code Format and Numerical Fields

Each CPT code consists of a five-character number or alphanumeric set. Great care is taken by the CPT Editorial Panel to avoid duplicating or overlapping procedural outcomes or aims. The ongoing revision process is necessary to keep the code set free from errors, relevant to current medical techniques and in the most efficient form possible.

Describing human medical conditions through any form of standardized means will never be a perfect solution – humans are all unique, and so are their medical problems. However, by continuous editing, revising and adhering to a rational process, the AMA has created what is arguably the most effective way of tracking and communicating health services and conditions

Room To Breathe: CPT Code Flexibility

With five digits, CPT codes can theoretically consist of 99,000 separate codes. However, in reality, that many codes are not needed. The AMA designed the system to be flexible and to have room for growth and change as medical procedures are updated, and in some cases, revolutionized.

Code Ranges and Assignments

The AMA arranges the different Category I CPT codes in the following ranges:

  • Evaluation and Management: 99201 – 99499
  • Anesthesia: 00100 – 01999; 99100 – 99140
  • Surgery: 10021 – 69990
  • Radiology: 70010 – 79999
  • Pathology and Laboratory: 80047 – 89398
  • Medicine: 90281 – 99199; 99500 – 99607

Subfields within the major sections allow for complete flexibility when determining a code for a specific procedure. Many standard codes exist that cover common occurrences, but CPT also provides for individual, unique and uncommon conditions and treatments to be coded accurately. The person doing the coding can also use code modifiers if necessary to adapt rarely used procedures to various areas of the body. Developing a skill for assigning CPT codes accurately usually takes specialized training to ensure the highest possible accuracy.

Advancing Forward With CPT

CPT has proven itself over the last five decades to be a robust and usable medical coding system. When used as intended, the reimbursements paid and useful data collected more than pay for the system’s upkeep. It is essential that as medical technology continues to change and evolve rapidly, the CPT guidelines and procedures are enabled to keep up with the task at hand. To remain relevant, CPT review processes will necessarily include an examination of the way the codes are interpreted and applied by the ones using the system.

As the rapid pace of medical advances continues to challenge the skills of medical coders, most agree that some degree of an overhaul to the CPT system will be necessary for the near future.

Even though the obstacles to keeping CPT vibrant are many, the opportunities to make a good system even better abound. The stakeholders involved–doctors, insurance companies, health workers, coding specialists and, not the least of all, the patients–must work together in a participatory effort. 

The task is to ensure that parity and accuracy are achieved in the prevalent medical coding system without a loss of the personal doctor-patient relationship that many believe is in jeopardy.

To keep CPT as a viable system, a commitment on the part of the medical community to help train those involved in not only the technical aspects of the system but in the intent of its use must be made. For CPT to continue into the future, its inherent simplicity at the core must be utilized to its full advantage. The AMA designed a system that is capable of living and growing well into the future if the buy-in is present from the medical community.


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