When we think of medical billing and coding, our first thought is of the coding systems that are critical to the process.
So what is a CPT-4 code anyway?
Current Procedural Terminology-4 (CPT-4) is the coding system that is used to provide a written description of the medical, surgical and diagnostic services that can be provided to a patient. CPT-4 codes are developed and maintained by the American Medical Association (AMA) and are updated yearly.
How are CPT-4 codes used?
A patient goes to the doctor complaining of being dizzy and having a headache. The doctor performs a new patient, problem focused exam and discovers that his blood pressure is elevated. He does a CT scan of the head and performs some blood work. All of his diagnostic tests are negative. The patient is diagnosed with high blood pressure and released home with medication.
CPT-4 codes allow the biller to describe every service and test that was provided to the patient in a concise and easy to understand format. Every service that a provider performs is translated from its word format into a CPT-4 code.
For example, a CT scan of the head is CPT-4 code 70470 (CT head w/wo contrast) and a new patient, problem focused exam is CPT-4 99201. Both of these codes, as well as the codes for the blood work, would be entered on the CMS 1500 form and billed to the carrier.
These codes tell the health insurance carrier everything about the patient’s encounter. So even though they were not present at the date of service, they are able to determine exactly what occurred solely by the codes entered on the billed claim.
This starts with careful, detailed documentation of every aspect of the patient’s visit, including: all of the services that were performed, what body part was involved, the detail or complexity of the visit, everything. This documentation is what will be used to determine which of the hundreds of CPT-4 codes are appropriate to use.
But CPT-4 coding is not as simple as picking a code that matches the service.
CPT-4 guidelines are strict and must be adhered to. Not every service can be billed, certain procedures are considered a normal part of the service, some services cannot be billed together, while other services, like multiple services same site, or same service different site, must be handled in accordance with the guidelines in the CPT-4 manual. The CPT-4 manual even lists guidelines on how office visits must be billed.
Coding is not a simple process, ALL of the rules must be adhered to or the provider's practice, and the biller, could be subject to unwanted scrutiny by the health carrier.
All of the rules are provided in the CPT-4 manual but you can also expand your knowledge by taking one of the Certified Procedural Coding classes and testing to obtain your Procedural Coding Certification.
CPT-4 codes are entered in field 24D of the CMS 1500 claim form.
CPT Codes fall into three categories: