CPT

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Current procedural terminology (CPT) is a set of terminology standards in the Unified Medical Language System (UMLS). CPT is used to identify the medical, surgical and diagnostic services and procedures. This set of terminology standards allow proper interoperability between the different elements of the health system, as physicians, patients, health insurance companies, administrators and others. It is used by insurance companies for the reimbursement purpose.

Introduction

According to the American Medical Association-AMA, the main provider and the owner of the CPT copyright, the Current Procedural Terminology. There is a law that obligate that the medical billing is to be done on a CPT basis. The AMA published the first edition in 1966, and we are now using the fourth edition of the CPT.

CPT is not free, it is copyrighted by AMA which also provide continuous guidance to those who use the CPT. It is maintained by the American Medical Association CPT Editorial Panel, that meet three times a year in order to allow continuous development and problem solving [1].

Features

The CPT is divided into three sub-categories:

Category I CPT codes

In this category the code consists of two parts: a five digit code + a descriptor nomenclature.

In order to include a new code to this category, certain criteria must be matched, which are the procedure/service described by this code must got the Food And Drug Administration-FDA approval, practiced in multiple locations by many health care-providers and is proven to be efficient.

Category II CPT codes

This set of codes is alphanumeric, optional and used for performance measurement. This is done through coding certain procedure, services, and/or test results that are considered to be indicators for the quality of the health care.

Category III CPT codes

This is a special set of codes which are also alphanumeric, but used to collect data to assess newly introduced procedures/services, in order to get the FDA approval or to spread this procedure/service. So it is used for research propose.

Updates

The CPT terminology are updated annually (an example for these updates is that for 2009 [2]), and this updates are published through the CPT© manual. In the manual tables describing the code contain fields for the code itself (numeric or alphanumeric), the title assigned to this code and the description.

References

  1. the American Medical Association official website: www.ama-assn.org. 1-3-2009.
  2. Albert Bothe, Jr., MD,FACS; Linda M. Barney, MD ,FACS; and Debra Mariani, CPC, Practice Affairs Associate, Division of Advocacy and Health policy. Current procedural Terminology: Changes for 2009. 2009.


Submitted by : Aly Khalifa


Choosing a Category I Code

A subset of CPT Category I codes are determined in accordance with Medicare's Evaluation and Management Guidelines as described here.[1] Determination of the appropriate code depends on several factors: 1) whether the patient is new or already established with the provider or clinic; 2) the setting, which may be an outpatient facility, hospital, emergency department, or nursing facility; and 3) the level of service performed. Levels of service in order of increasing complexity are problem-focused, expanded problem focused, detailed, and comprehensive. The amount billed must be supported by the level of service, which is reflected in the CPT code.

Selecting the appropriate code for visits that primarily utilize counseling or coordination of care is dependent on the amount of time spent during the visit. For other visits, the level of service depends on the history, examination, and medical decision making.

History

The history must include the chief complaint and a history of the present illness (HPI), and it may include a review of systems (ROS) and the patient's past, family, and/or social history. All responses, positive and negative, must be documented to support the level of care. Elements of the HPI include location of problem, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms. The HPI may be brief, including three elements, or it may be extended, containing at least four elements or the status of at least three chronic or inactive conditions.

ROS systems are eyes; ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary; neurological; psychiatric; endocrine; hematologic/lymphatic; allergic/immunologic; and constitutional symptoms such as fever and weight loss. There are three levels of ROS: problem pertinent focuses on the system directly related to the chief complaint; extended includes the relevant system and two to nine other systems; and complete includes the relevant system and all other systems.

Examination

The complexity, or type, of exam depends on the number of organ systems examined and the specific exams performed. CMS outlines each system and a list of exams, as well as the number of exams to perform for each level of complexity.

Medical decision making

The type of decision making depends on the number of diagnoses or management options considered, complexity of records and tests to be reviewed, and the risk of complications with the condition.

Advantages of Electronic Health Records (EHR) in Coding and Billing

All of these factors guide the selection of the appropriate visit code. This is not straightforward, and consequently many providers use a code signifying a lower level of visit in order to ensure their documentation supports their coding and billing claims.[2] Because of the highly structured nature of EHRs, visit documentation is very thorough. Many EHRs have billing functions, including the capacity to generate CPT codes. The thoroughness of the documentation results in more accurate coding, reducing the amount of undercoding. One study of small clinics who had used their EHR for several years found increased coding levels generated an average revenue increase of $16,929 per provider per year.[3]


References

  1. Department of Health and Human Services Centers for Medicare & Medicaid Services. Evaluation and management services guide. CMS [Internet]. 2010 [cited 2011 Nov 15]. Available from https://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf.
  2. Fishman ES. Evaluation and management coding and electronic health records. EMRConsultant [Internet]. 2011 [cited 2011 Nov 13]. Available from: http://www.emrconsultant.com/education/emcoding
  3. Miller RH, West C, Brown TM, Sim I, Ganchoff C. The value of electronic health records in solo or small group practices. Health Aff 2005; 24(5):1127-1137.


Submitted by Tracy Edinger