What are CPT® Codes?

In the last Coding 101 blog that focused on HCPCS codes we discussed that there are 2 divisions of the code set into level I and level II. That focused on level II codes, in this blog we’ll discuss HCPCS Level I codes, also known as CPT® codes, short for Common Procedural Terminology.

CPT® codes were first published in 1966, with the intent of standardizing terminology among physicians and other providers for healthcare services and procedures. They are owned, created, and managed by the American Medical Association (AMA). In 1983, The Centers for Medicare & Medicaid Services (CMS) adopted CPT® and its own HCPCS Level II code set as the required standard for reporting healthcare services for reimbursement among Medicare, Medicaid and commercial payors.

CPT® codes are broken out into Category I, Category II and Category III codes. Category I codes are most commonly used by healthcare providers to report medical and professional services and procedures. Evaluation and Management (E/M) codes represent the most commonly used Category I codes. There are over 7,000 Category I codes and they are mandatory for reporting and reimbursement purposes. Category I codes are five-digit numeric code and they updated on an annual basis with changes effective January 1 of the next calendar year with the exception of vaccine codes which are updated for July 1 and January 1 with effective dates for use six months after they are published.

Category II codes are optional and are used by an incentive based program developed by CMS called the Physician Quality and Reporting System (PQRS) to provide performance measurement for certain medical conditions. These codes are designed to reduce administrative burdens and can be used in conjunction with Category I codes. Category II codes are released three times a year and are effective three months after the publication date. These codes are alphanumeric with the letter “F” in the last position (i.e. 4035F Influenza immunization recommended (COPD) (IBD)).

Category III codes are temporary codes for emerging technology, services and procedures. Category III codes are updated twice a year on January 1 and July 1 (same cycle as Category I vaccine codes). They are also alphanumeric but with the letter “T” in the last position (i.e. 0347T Placement of interstitial device(s) in bone for radiostereometric analysis (RSA)).

Although HCPCS Level II codes are generally utilized for specific drugs and products, the Medicine section of Category I CPT® codes contain codes for vaccines/toxoids and immune globulins, as well as administration codes. RJ Health Systems includes this subset of codes on ReimbursementCodes.com because they can be associated with NDCs and HCPCS Level II Codes for reimbursement (i.e. 90389 Tetanus immune globulin (TIg), human, for intramuscular use AND[i] 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)).

At RJ Health Systems, our expertise in the coding of drugs has led to the establishment of industry standard data and the development of productivity and analysis tools that assist our various types of clients with Medical Pharmacy trend management. As the industry’s authoritative source, we maintain an updated pricing database for all drug codes, which is utilized by the vast majority of health plans in the United States. Through the use of our data and tools our customers realize increases in claim accuracy and pricing, which results in savings.

To see our various tools, or to learn more about our data please contact info@rjhealthsystems.com for a demonstration.