Medical billing and coding can seem complex and overwhelming to healthcare professionals. Understanding the ins and outs of the Current Procedural Terminology (CPT) coding system is essential for accurate and efficient billing.
In this comprehensive guide, we will understand CPT codes, explore their significance in healthcare reimbursement, and provide insights into commonly used codes and modifiers.
Let’s get started…
What Are CPT Codes?
CPT codes is code set developed by the American Medical Association for the services rendered by healthcare providers.
Commonly Used CPT Codes and Modifiers
Here, we present a list of commonly used CPT codes and modifiers. However, we also recommend consulting official resources for complete descriptions and listings of all current codes and modifiers.
97760: Orthotics management and training, this includes assessment and fitting and initial encounter, every 15 minutes.
97761: Prosthetics training and initial encounter, every 15 minutes.
97763: Orthotics/prosthetics management and/or training, subsequent encounter, every 15 minutes.
97127 (HCPCS Code G0515): Development of cognitive skills to improve attention, memory, and problem-solving, every 15 minutes.
Modifiers
GP: Indicates that services are provided as part of an outpatient physical therapy plan of care.
25: used when providing a re-evaluation and therapy on the same day and invoicing for it.
KX: Indicates that a Medicare patient has exhausted their rehab services benefits and the clinician certifies that the services given are medically necessary.
Moreover, It’s crucial to ensure appropriate documentation to support the CPT code. Failure to provide proper documentation may result in claim denial.
Common CPT Codes for Physical Therapy
97110 – Therapeutic exercises: This code is for services that improve strength, endurance, range of motion, and flexibility.
97112 – Neuromuscular reeducation: It involves retraining muscles and nerves to improve coordination, balance, and proprioception.
97116 – Gait training therapy: This code is used when the focus of therapy is on improving a patient’s ability to walk or regain normal walking patterns.
97140 – Manual therapy techniques: It includes hands-on techniques such as joint mobilization, soft tissue mobilization, and manual traction.
97530 – Therapeutic activities: This code covers dynamic activities to improve functional abilities, such as transfers, balance activities, and coordination exercises.
97150 – Group therapy: It is used when multiple patients receive therapy simultaneously under the supervision of a physical therapist.
97535 – Self-care/home management training: This code is used for teaching patients how to independently perform daily activities, such as dressing, grooming, and home safety.
Athletic Training Evaluation Codes
For athletic trainers, understanding evaluation codes is vital.
Here are the evaluation codes specific to athletic training:
97169: Athletic Training evaluation, low complexity.
97170: Athletic Training evaluation, moderate complexity.
97171: Athletic Training evaluation, high complexity.
97172: Athletic Training re-evaluation.
The level of the athletic training evaluation is determined on the basis of factors such as the complexity of the patient’s condition, the time spent evaluating the patient, and the decision-making involved in developing a treatment plan.
It’s essential for athletic trainers to accurately assign the appropriate evaluation code to ensure proper reimbursement and documentation.
Ten Common Radiology CPT Codes
- 70450: CT Head without contrast
- 71020: Chest X-ray, 2 views
- 72170: MRI Spine without contrast
- 74177: CT Abdomen and Pelvis with contrast
- 77057: Mammography, screening, bilateral
- 78452: Nuclear medicine study, limited area
- 76830: Ultrasound, transvaginal
- 72195: MRI of Lower Extremity without contrast
- 74018: Contrast injection for CT scan
- 74220: Upper GI series with small bowel follow-through.
Three common MRI CPT codes
72158 – MRI of the Spine: This code is for diagnostic imaging of the spinal region, including the cervical (neck), thoracic (mid-back), and lumbar (lower back) areas.
73221 – MRI of the Upper Extremity: This code covers MRI scans of the joints and soft tissues in the upper extremities, including the shoulder, arm, elbow, wrist, and hand.
73721 – MRI of the Lower Extremity: This code is for MRI scans of the joints and soft tissues in the lower extremities, including the hip, thigh, knee, lower leg, ankle, and foot.
Four Sleep Study CPT Codes
95810 – Polysomnography (PSG): This code is for the diagnostic evaluation of sleep patterns and disorders. It involves monitoring various physiological parameters during sleep, including brain activity, eye movement, muscle activity, heart rate, and respiratory effort.
95811 – Polysomnography with continuous positive airway pressure (CPAP) titration: This code is used when a CPAP device is used during the sleep study to determine the optimal pressure settings for managing sleep-related breathing disorders, such as obstructive sleep apnea.
95807 – Multiple sleep latency test (MSLT): This code covers the evaluation of daytime sleepiness and the diagnosis of certain sleep disorders, such as narcolepsy. It involves multiple nap opportunities throughout the day with monitoring of sleep onset and sleep stages.
95806 – Home sleep apnea testing (HSAT): This code is for sleep studies in a patient’s home environment. It typically involves the use of portable devices to monitor respiratory parameters and diagnose sleep-related breathing disorders, such as obstructive sleep apnea.
Five Common Telehealth CPT Codes
99441: Telephone evaluation and management service by a physician or other qualified healthcare professional, 5-10 minutes of medical discussion.
99442: Telephone evaluation and management service by a physician or other qualified healthcare professional, 11-20 minutes of medical discussion.
99443: 21–30 minute medical consultation over the phone with a doctor or other qualified healthcare expert for evaluation and management.
98966: Five to ten minutes of medical consultation over the phone with a qualified non-physician healthcare expert who offers assessment and management services.
98967: 11–20 minutes medical consultation over the phone with a qualified non-physician healthcare expert.
The Importance of CPT Codes in Reimbursement
The Centers for Medicare and Medicaid Services (CMS) utilize the CPT coding system to determine reimbursement for Medicare providers. Each CPT code has a relative value unit (RVU), which is reviewed periodically.
RVUs play a crucial role in analyzing reimbursement, determining physician compensation and productivity, and assessing practice staffing and operating costs. Commercial insurers often base their reimbursement levels on the Medicare fee schedule or RVUs.
Six Tips for Accurate CPT Coding
To ensure accurate CPT coding and avoid potential billing errors or denials, healthcare professionals should keep the following tips in mind:
Stay Updated: The Editorial panel updates CPT codes regularly. They introduce new codes and revise or delete the existing ones. Hence, it’s crucial to stay updated with the latest coding changes by referring to official sources and attending webinars/conferences.
Code to the Highest Level of Specificity: When assigning CPT codes, it’s important to select the code that most accurately describes the service. Coding to the highest level of specificity ensures accurate reimbursement and reduces the risk of audits or compliance issues.
Understand Documentation Requirements: Adequate documentation is key to supporting the assigned CPT codes. Healthcare professionals should be familiar with the specific documentation requirements for each code, including the level of detail to justify the services provided.
Properly Use Modifiers: Modifiers provide additional information about a service or procedure and can impact reimbursement. It’s important to use modifiers correctly and under the payer’s guidelines to avoid claim denials or delays.
Regularly Review Coding Guidelines: Familiarize yourself with coding guidelines and instructions provided by the AMA, CMS, and other relevant organizations. These guidelines provide specific instructions on coding conventions, bundling, and unbundling rules, and documentation requirements.
Seek Coding Support: If you’re unsure about a particular code or coding scenario, don’t hesitate to seek coding support or consult with a certified coder. They can provide valuable guidance and help ensure accurate coding and billing practices.
Conclusion
Mastering consult CPT codes is crucial for healthcare professionals working on medical billing and coding. Understanding the significance of CPT codes in reimbursement, familiarizing oneself with commonly used codes and modifiers, and following accurate coding practices are essential for efficient and accurate billing.
By staying updated with coding changes, documenting services appropriately, and adhering to coding guidelines, healthcare professionals can navigate the world of medical billing with confidence and ensure deserving reimbursement for the services they provide.
