What Is CPT, and How Can You Use It Effectively?

CPT (Clinical Procedure Terminology) is a compilation of codes and descriptors used by medical providers to document medical services and procedures. CPT codes are established by the Centers for Medicare and Medicaid Services (CMS) and supported by carriers and claims clearinghouses. In this guide, you’ll learn about the purpose of CPT codes and how to use them correctly in medical records.

What is CPT?

Clinical Procedure Terminology (CPT) is a set of codes and instructions to report medical, surgical, and diagnostic services. CPT codes are established by the American Medical Association (AMA), updated each year, and divided into two major categories: Evaluation and Management (E/M) for office visits and other services such as laboratory tests, X-rays, injections, and surgical procedures. The codes also serve as descriptors of medical services.

What are the Benefits of Using CPT?

The use of CPT codes has numerous benefits for both healthcare providers and patients. CPT codes help standardize communication between healthcare professionals, providing an accurate, efficient way to describe medical services and procedures. Moreover, they enable insurance reimbursements and can improve accuracy in billing. Accurate coding can increase patient satisfaction by ensuring they receive the high-quality care they deserve.

How to Use CPT for Maximum Effectiveness?

When using CPT codes for maximum effectiveness, it is essential to be accurate and up-to-date. The CPT coding manual is updated every October of every year, and the proficient coder should be aware of these changes and how they affect their practice. CPT codes should accurately reflect the work done and the services provided. Pay attention to the specificity of each code and add qualifiers when needed to ensure an accurate description. Additionally, use modifiers when applicable in order to ensure correct reimbursement via insurance providers. Following these steps will help you use CPT effectively while maximizing patient satisfaction and accuracy in billing.

Important Considerations when Working with CPT

When using CPT, it is important to take into consideration the nature of the services provided and the documentation that supports their performance. It’s important to ensure accuracy by cross-checking each step in the coding process and verifying any changes with a more experienced professional in order to stay up-to-date on all CPT codes. Additionally, be sure to pay attention to common definitions when differentiating between types of code levels as well as classification codes for specific treatments and procedures.

Tips and Tricks for Making CPT Easier

In addition to understanding the coding system, there are a few other tips and tricks you can use to help make using CPT easier. First, remember that if multiple codes can support a procedure, you should always put the most-specific code and include the additional codes in brackets afterward. When trying to find a specific code, start with the index rather than the table of contents for words mentioned in the SOAP notes or History of Present Illness. Additionally, try your best to group related services for a single code whenever possible in order to reduce confusion and ensure all work is accurately captured. Finally, keep your codes up-to-date by obtaining provider bulletins from the AMA or consulting a Medical Billing Professional such as Sosa Practice Partners.