Medical Coding: Get an Overview of Three CPT Code Categories


The CPT codes are determined by a 17-member editorial panel. And of the 17 members, 15 are physician. And then of those 15, 11 come from various specialist society. One comes from the Blue Cross and Blue Shield Association. One comes from American Health Insurance Plan. One comes from the American Hospital Association and one comes from CMS. Now they're all physicians. Those 15 members are all physicians. The other two members of the CPT editorial panel are other health care professionals like nurse, a physical therapist, other people who have an interest in the medical coding.

And if you think about in the medicine section of the CPT book, there are quite of you, codes that are not billed by physicians or the services are not performed by physicians. So, we have two of those individuals on the CPT editorial panel. But these people the decision makers. They decide whether something is going to be a CPT medical coding and billing code option. They decide whether a service is going to be a Category I code or a Category III code. So we'll talk about that decision.

Then they are actually advised by a bigger committee of the AMA called the CPT Advisory Committee. And this just gives them a bigger pool of physicians and a bigger pool of knowledge and experience to draw on when making these decisions. Then that committee includes mostly physicians but other professionals, peoples who are experts on performance measures for example. So we've got this panel that determines the CPT code.


And we actually have three different categories of CPT code. Now the one that we've always known, the familiar five-digit codes are Category I code. And In the past, before we actually have Category III codes, it took a long time to get a CPT code.

And we would be less billing an unlisted code sometimes for several years before we actually could get a code because in order to be a Category I code, again that historical CPT code we've always known, in order to get a Category I code, the service has to be FDA approved. It has to be a distinct service that it can't be part of another service or something that could possible be identified partially by another code. It's got to a distinct service.

It has to be done all across the country. It can't be something that one physician in Podunk, Alabama does. It has to be a procedure that is provided widely across the country. And it has to be clinically efficacious. It has to be effective. There has to be use for it. You have to be able to support that efficacy in literature. So we've got to have it. They got to be FDA approved, going to be done all over the country. And it's got to be useful. It's got to present some benefit to that patient.

Well, we don't necessarily know that a service is going to be beneficial to a patient until we've done it quite a few times. Until we've done it enough time to study it. So, we used to have to wait for several years to look at it (thoroughly) to see if they were able to wait for their FDA approval, to study and see where they were done and how often they were done, and to see how effective they work. So it took a long time.

Category II medical coding and billing codes are fairly new. These are the performance measures. If you're involved in PQRI which I certainly have you are, if your practice is involved in PQRI, the Physician Quality Reporting Information there, then you're familiar with the Category II codes. They're the performance measures. They're four digits followed by the letter F.

The Category III codes are followed by the letter T which is interesting because they're stand for new technology. So that's sort of easy to remember. The T is for technology.

That's the distinction there. The Category I code, the five digits, they're all numbers. Category II code, four digit followed by the letter F. Category III code, four digit followed by the letter T.

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