Current Procedural Terminology
Medical coding used in the United States
The Current Procedural Terminology (CPT) code set is a medical code set maintained by the American Medical Association through the CPT Editorial Panel. The CPT code set (copyright protected by the AMA) describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
New editions are released each October. The current version is the CPT It is available in both a standard edition and a professional edition.
CPT coding is similar to ICD-9 and ICD coding, except that it identifies the services rendered, rather than the diagnosis on the claim (ICDCM was created for diagnostic coding- it took the place of Volume 3 of the ICD-9). The ICD code sets also contain procedure codes (ICDPCS codes), but these are only used in the inpatient setting.
CPT is currently identified by the Centers for Medicare and Medicaid Services (CMS) as Level 1 of the Healthcare Common Procedure Coding System.
The Current Procedural Terminology (CPT) was developed by the American Medical Association (AMA).
Types of code
There are three types of CPT code: Category I, Category II, and Category III.
Category I CPT Code(s). There are six main sections:
Codes for evaluation and management: –
Codes for anesthesia: –; –
Codes for surgery: –
Codes for radiology: –
Codes for pathology and laboratory: –
Codes for medicine: –; –; –
- (–) immune globulins, serum or recombinant prods
- (–) immunization administration for vaccines/toxoids
- (–) vaccines, toxoids
- (–) psychiatry
- (–) biofeedback
- (–) dialysis
- (–) gastroenterology
- (–) ophthalmology
- (–) special otorhinolaryngologic services
- (–) cardiovascular
- (–) noninvasive vascular diagnostic studies
- (–) pulmonary
- (–) allergy and clinical immunology
- (–) endocrinology
- (–) neurology and neuromuscular procedures
- (–) central nervous system assessments/tests (neuro-cognitive, mental status, speech testing)
- (–) health and behavior assessment/intervention
- (–) hydration, therapeutic, prophylactic, diagnostic injections and infusions, and chemotherapy and other highly complex drug or highly complex biologic agent administration
- (–) photodynamic therapy
- (–) special dermatological procedures
- (–) physical medicine and rehabilitation
- (–) medical nutrition therapy
- (–) acupuncture
- (–) osteopathic manipulative treatment
- (–) chiropractic manipulative treatment
- (–) education and training for patient self-management
- (–) non-face-to-face nonphysician services
- (–) special services, procedures and reports
- (–) other services and procedures
- (–) home health procedures/services
- (–) medication therapy management services
CPT II codes describe clinical components usually included in evaluation and management or clinical services and are not associated with any relative value. Category II codes are reviewed by the Performance Measures Advisory Group (PMAG), an advisory body to the CPT Editorial Panel and the CPT/HCPAC Advisory Committee. The PMAG is composed of performance measurement experts representing the Agency for Healthcare Research and Quality (AHRQ), the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA) and the Physician Consortium for Performance Improvement. The PMAG may seek additional expertise and/or input from other national health care organizations, as necessary, for the development of Category II codes. These may include national medical specialty societies, other national health care professional associations, accrediting bodies and federal regulatory agencies.
Category II codes make use of an alphabetical character as the 5th character in the string (i.e., 4 digits followed by the letter F). These digits are not intended to reflect the placement of the code in the regular (Category I) part of the CPT codebook. Appendix H in CPT section contains information about performance measurement exclusion of modifiers, measures, and the measures' source(s). Currently there are 11 Category II codes. They are:
- (F–F) Composite measures
- (F–F) Patient management
- (F–F) Patient history
- (F–F) Physical examination
- (F–F) Diagnostic/screening processes or results
- (F–F) Therapeutic, preventive or other interventions
- (F–F) Follow-up or other outcomes
- (F–F) Patient safety
- (F–F) Structural measures
- (F–F) Non-measure claims-based reporting
CPT II codes are billed in the procedure code field, just as CPT Category I codes are billed. Because CPT II codes are not associated with any relative value, they are billed with a $ billable charge amount.
- Category III CPT Code(s) – Emerging technology (Category III codes: TT)
Major psychotherapy and psychiatry revisions
The CPT code revisions in were part of a periodic five-year review of codes. Some psychotherapy codes changed numbers, for example changed to for individual psychotherapy of a similar duration. Add-on codes were created for the complexity of communication about procedures. Family therapy and psychological testing codes were among those that were unchanged. 
Criticism of copyright
CPT is a registered trademark of the American Medical Association, and its largest single source of income. The AMA holds the copyright for the CPT coding system. However, in Practice Management v. American Medical Association the U.S. Court of Appeals for the Ninth Circuit held that while the AMA owned the copyright, it could not enjoin a competitor on the basis that the AMA had misused its copyright. Practice Management had argued that the publication of the CPT into federal regulation invalidated the copyright; the general debate around copyright and regulation access was revived in  by a petition motivated by an Administrative Conference of the United States recommendation.
Despite the copyrighted nature of the CPT code sets, the use of the code is mandated by almost all health insurance payment and information systems, including the Centers for Medicare and Medicaid Services (CMS) and HIPAA, and the data for the code sets appears in the Federal Register. It is necessary for most users of the CPT code (principally providers of services) to pay license fees for access to the code.
Limited CPT search offered by the AMA
In the past, AMA offered a limited search of the CPT manual for personal, non-commercial use on its web site.
As the AMA decided in April , the Current Medical Terminology (CMT) handbook was first published in June – to standardize terminology of the Standard Nomenclature of Diseases and Operations (SNDO) and International Classification of Diseases (ICD), and for the analysis of patient records, and was aided by an IBM computer. Procedural information was dropped in the transition from the SNDO to CMT, but was released separately as the Current Procedural Terminology in 
- ^AMA (CPT) CPT ProcessArchived May 11, , at the Wayback Machine
- ^Laura Southard Durham (1 June ). Lippincott Williams and Wilkins' Administrative Medical Assisting. Lippincott Williams and Wilkins. pp.2–. ISBN. Retrieved 26 May
- ^Michelle Abraham; Jay T. Ahlman; Angela J. Boudreau; Judy L. Connelly; Desiree D. Evans; Rejina L Glenn (30 October ). CPT Standard Edition. American Medical Association Press. ISBN. Retrieved 26 May
- ^American Medical Association; American Medical Association (COR); Michelle Abraham; Jay T. Ahlman; Angela J. Boudreau; Judy L. Connelly (30 October ). CPT Professional Edition. American Medical Association Press. ISBN. Retrieved 26 May
- ^Alexander, Sherri, Pharm.D. (1 November ). "Overview of inpatient coding"(PDF). American Journal of Health-System Pharmacy. 60. Archived from the original(PDF) on 17 September Retrieved 30 April
- ^ abCenters for Medicare and Medicaid ServicesArchived July 20, , at the Wayback Machine
- ^"Criteria for CPT® Category I and Category III codes". American Medical Association. Retrieved 22 September
- ^Marie A. Moisio (8 April ). Medical Terminology for Insurance and Coding. Cengage Learning. pp.80–. ISBN. Retrieved 26 May
- ^"Anesthesia for Procedures on the Upper Abdomen". Archived from the original on Retrieved , Anesthesia for procedures on the upper abdomen
- ^"Anesthesia for lower abdomen".,Anesthesia for procedures on the lower abdomen
- ^AMA coding manual
- ^Centore, Anthony. "The Psychotherapy Codes: An Overview for Psychologists". American Psychological Association. Retrieved 7 August
- ^Rosenthal, Elisabeth (). "Those Indecipherable Medical Bills? They're One Reason Health Care Costs So Much". The New York Times.
- ^AMA (CPT) CPT LicensingArchived October 21, , at the Wayback Machine
- ^"Practice Management Info. v. American Medical Ass'n, F. 3d - Court of Appeals, 9th Circuit ". Retrieved
- ^Pamela, Samuelson (). "Questioning Copyrights in Standards". Boston College Law Review. 48 (1).
- ^Contreras, Jorge (). "Technical Standards and Bioinformatics". BIOINFORMATICS LAW. SSRN
- ^"Administrative Conference Recommendation Incorporation by Reference Adopted December 8, "(PDF). Administrative Conference of the United States. Archived(PDF) from the original on Retrieved
- ^"Archived copy"(PDF). Archived from the original(PDF) on Retrieved CS1 maint: archived copy as title (link)
- ^AMA (). "cpt® Code/Relative Value Search". Retrieved from "Archived copy". Archived from the original on Retrieved CS1 maint: archived copy as title (link).
- ^"AMA to Publish Handbook of Medical Terminology". Journal of the Mississippi State Medical Association: 16– April
- ^Moriyama, IM; Loy, RM; Robb-Smith, AHT (). Rosenberg, HM; Hoyert, DL (eds.). History of the statistical classification of diseases and causes of death(PDF). Hyattsville, MD: National Center for Health Statistics. p.7.
- ^Borman, Karen R (). "Medical Coding in the United States: Introduction and Historical Overview". In Savarise, Mark; Senkowski, Christopher (eds.). Principles of Coding and Reimbursement for Surgeons. Springer. p.4. ISBN.
CPT® Professional (Spiral)
Only the AMA, with the help of physicians and other experts in the health care community, creates and maintains the CPT code set. No other codebook can provide the official guidelines to code medical services and procedures properly. The AMA also takes the copyright protection of its content very seriously and is committed to providing the most effective anti-piracy efforts for its authors and readers. To help combat print piracy, protect our intellectual properties and ensure our customers' right to authentic AMA-certified content, the CPT(R) Professional is equipped light-yellow dots on most pages. As a result of the implementation of this anti-piracy technology, this code book cannot be reproduced by photocopy or scan in accordance with current copyright rules and laws.
- CPT® Changes, CPT® Assistant, and Clinical Examples in Radiology citations — provides cross-referenced information in popular AMA resources that can enhance your understanding of the CPT® code set
- E/M code changes – gives guidelines on the updated codes for office or other outpatient and prolonged services section incorporated
- A comprehensive index — aids you in locating codes related to a specific procedure, service, anatomic site, condition, synonym, eponym or abbreviation to allow for a clearer, quicker search
- Anatomical and procedural illustrations — help improve coding accuracy and understanding of the anatomy and procedures being discussed
- Coding tips throughout each section — improve your understanding of the nuances of the code set
- Enhanced code book table of contents — allows users to perform a quick search of the code book’s entire content without being in a specific section
- Section-specific table of contents — provides users with a tool to navigate more effectively through each section’s codes
- Summary of additions, deletions and revisions — provides a quick reference to changes without having to refer to previous editions
- Multiple appendices — offer quick reference to additional information and resources that cover such topics as modifiers, clinical examples, add-on codes, vascular families, multianalyte assays and telemedicine services
- Comprehensive E/M code selection tables — aid physicians and coders in assigning the most appropriate evaluation and management codes
- Adhesive section tabs — allow you to flag those sections and pages most relevant to your work
- More full color procedural illustrations
- Notes pages at the end of every code set section and subsection
When billing for services performed by a physician, several coding resources are used. Each practice may use a variety of billing publications and resources; however, the basic billing tools include the Current Procedural Terminology (CPT), the Healthcare Common Procedure Coding System (HCPCS), and International Classification of Diseases, 9th Revision, Clinical Modification (ICDCM).
In order to bill appropriately for services and assign correct diagnosis codes, it is imperative to have the most up-to-date coding materials. Physicians should purchase updated coding publications every year to ensure that their billing and coding systems are accurate. Here is a brief overview of the publications mentioned, the available dates, and the effective dates for each.
The CPT book provides a method of reporting physician services by identifying and describing medical services. The American Medical Association (AMA; Chicago, IL) publishes the CPT book annually, and changes are effective on January 1 of each year. CPT codes are recognized nationally by public and private payers, and annual changes in CPT are typically recognized by these payers. The CPT book is typically available for purchase during the month of October.
The AMA publishes many supplements to the CPT book, and two worth noting are CPT Changes: An Insider's View and CPT Assistant. The first publication provides a detailed review of the current year's additions, revisions, and deletions to CPT. The latter guide is published monthly and is the official companion to the CPT book.
The HCPCS contains codes identifying medical services, supplies, and items that are not represented by CPT codes. The HCPCS codes begin with a letter followed by four numbers. These codes include Medicare G-codes, E-codes for durable medical equipment, S-codes for temporary national services, and J-codes for drugs.
This publication is updated annually and is effective January 1 of each year. HCPCS codes are recognized by Medicare, Medicaid, and most other payers, and changes in HCPCS codes are typically recognized by these payers. The publication is available from a number of private sources, but is typically available for purchase in December.
The ICDCM has three volumes. Volumes 1 and 2 list codes for various diagnoses. Volume 3 consists of codes for procedures and is used by hospitals.
This publication is updated annually, and changes are effective October 1 of each year. ICDCM codes are recognized by public and private payers. This publication is typically available for purchase in September.
The official publication for ICDCM coding guidelines and advice is the Coding Clinic for ICDCM. This publication is available through the American Hospital Association Central Office on ICDCM, and is published quarterly.
As a reminder, the Centers for Medicare Medicaid Services (CMS) no longer allows a day grace period to report old ICDCM codes. Medicare carriers and fiscal intermediaries will not accept discontinued ICDCM codes on claims with dates of service after the October effective date.
Practical Tips for the Practicing Oncologist
ASCO is currently updating its publication, Practical Tips for the Practicing Oncologist. The 4th edition will offer answers to the most frequently asked questions about coding, reimbursement, and regulatory policies affecting oncology practices. The new edition will be renamed Practical Tips for the Oncology Practice and is expected to be available in the first quarter of
Payment Hold Reminder
The Centers for Medicare Medicaid Services (CMS) will implement a payment hold on all paper and electronic claims including initial, adjusted, and Medicare Secondary Payer (MSP) claims. The payment hold was mandated by the Deficit Reduction Act of
Claims will be held from September 22, , through September 30, During this 9-day period, interest will not be accrued or paid for delayed payment. CMS states that payment for claims held will be made on October 2,
More detailed information on this payment hold can be found in CMS Transmittal , dated May 10, , at http://www.cms.hhs.gov/Transmittals/downloads/RCP.pdf.
The corresponding Medicare Learning Network (MLN) Matters article can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MMpdf.
Articles from Journal of Oncology Practice are provided here courtesy of American Society of Clinical Oncology
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CPT® Professional Edition is the definitive AMA-authored resource to help healthcare professionals correctly report and bill medical procedures and services. Healthcare professionals want accurate reimbursement. Payers want efficient claims processing. Correct reporting and billing of medical procedures and services begins with CPT® Professional Edition.
Only the AMA, with the help of physicians and other experts in the healthcare community, creates and maintains the CPT code set. No other codebook has the accurate, complete official guidelines for the latest and current procedural terminology for procedures and services to help you code medical services and procedures properly. The AMA also takes the copyright protection of its content very seriously and is committed to providing the most effective anti-piracy efforts for its authors and readers.
To help combat print piracy, protect our intellectual properties, and ensure our customers' right to authentic AMA-certified content, the CPT® Professional Edition is equipped with nonintrusive light-yellow dots on almost every page of the codebook. As a result of the implementation of this anti-piracy technology, this codebook cannot be reproduced by photocopy or scan in accordance with current copyright rules and laws.
The CPT® Professional Edition codebook covers hundreds of code, guideline and text changes and features:
- CPT® Changes, CPT® Assistant, and Clinical Examples in Radiology citations — provides cross-referenced information in popular AMA resources that can enhance your understanding of the CPT code set
- A comprehensive index — aid in locating codes related to a specific procedure, service, anatomic site, condition, synonym, eponym or abbreviation to allow for a clearer, quicker search
- Anatomical and procedural illustrations — help improve coding accuracy and understanding of the anatomy and procedures discussed
- Coding tips throughout each section — improve understanding of the nuances of the code set
- Enhanced codebook table of contents — enable a quick search of the codebook’s content for quick access
- Section-specific table of contents — provide a useful tool to navigate effectively and quickly through each section’s codes
- Summary of additions, deletions and revisions — provide a summary and quick reference of the changes in the codes without having to compare editions
- Multiple appendices — offer additional information for modifiers, clinical examples, add-on codes, vascular families re-sequenced codes, and MAAAs and PLA services
- New Appendix Q — provide coronavirus disease (COVID) vaccines and their associated administration codes
- New Appendix R — provide digital medicine services taxonomy
- Comprehensive E/M code selection tables — aid physicians and coders in assigning the most appropriate evaluation and management codes
- Notes pages at the end of every code set section and subsection
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