Medical billing is conducted in the specialized language of medical coding. When professional medical billers submit clean claims to commercial health insurance companies, Medicare, Medicaid, or Tricare, they communicate what procedures were performed to diagnose or treat a patient. These medical procedures are usually described in Current Procedural Terminology (CPT).

The basis of healthcare documentation is the patient’s medical record. The information contained in this record is then translated into uniform, industry-standard code. When medical, surgical or diagnostic services are provided, they are translated into CPT codes and reported to third-party payers for reimbursement. A professional medical biller and a certified medical coder have the training to understand and use apply this specialized vocabulary.

The Language of CPT

99213 means nothing to the man on the street. To a professional medical biller or a certified medical coder, it means an “office or other outpatient visit for the evaluation and management of an established patent which requires at least 2 of 3 key components: an expanded problem focussed history; an expanded problem focused examination; medical decision making of low complexity.” Five numbers can contain a wealth of specific information for people who speak the language. It is this understanding that keeps America’s healthcare system running, and profitable.

CPT is maintained and annually updated by the American Medical Association (AMA). The AMA CPT Editorial Board annually reviews current technology and common medical practice through its advisory committees, with input from professional specialty organizations, to assign codes to describe specific medical procedures.

As the example above shows, CPT deals with technical language, assuming an understanding of anatomy and physiology, as well as a familiarity with the art and science of healthcare delivery. The CPT codebook explicitly states in its introduction, “Do not select a CPT code that merely approximates the service provided.” CPT is designed and intended to report accurate information for statistical and reimbursement purposes. A procedure either fits a CPT definition or it does not. Based on the documentation in a patient’s medical record, a specific procedure can be reported. If a procedure does not meet the definition defined by the AMA through CPT, the service should be reported “using the appropriate unlisted procedure or service code.” CPT does not allow for wiggle room.

Medical Billers Speak in Code

A professional medical biller and a certified medical coder is trained to use CPT to accurately describe medical services through the use of standardized code. While the CPT codebook is the necessary tool to do this, professional medical billers and professional medical coders have the background to understand what the codes mean, and how they should be assigned.

CPT is divided into sections according to medical specialty. Professional organizations offer advice to the AMA throughout the year to limit, expand, or replace code definitions. Codes are divided into sets that cover the range of an assumed medical specialty, but no healthcare provider is limited to using codes from only one section. CPT describes medically necessary procedures. When a physical therapist, who usually only provides services enumerated in the physical therapy section of CPT performs a debridement of a wound, he or she uses the code found in the surgical section of CPT to report that service. When a medically necessary service is provided by a licensed healthcare provider, the most accurate CPT code is used to describe that service.

The Structure of CPT

CPT codes are also known as HCPCS Level I codes when they are communicated to Medicare payers. CPT codes are the codes used to describe common medical procedures. Every medical insurance payer recognizes CPT codes as the standard by which medical procedures are described in a universal language with specific meaning.

Each chapter of CPT starts with a general introduction to the code set being described for a specialty. It describes how evaluation and management services, codes 99201-99499, should be used in conjunction with the codes with in each specific set. Each introduction also instructs medical coders and billers how to report follow-up care, follow-up, therapy, materials supplied by a healthcare provider, and how to report separate procedures.

Some CPT procedures contain a technical component, the actual performance of a procedure, and a professional component, the interpretation of the results of a procedure by a qualified professional. Some codes are all-inclusive, combining both the technical and professional components. Professional training allows medical billers and medical coders to make a determination of which aspect should be reported through appropriate modifications to the codes.

CPT contains appendices that list the possible modifiers acceptable according to the AMA’s coding methodology. CPT also lists place-of-service codes to describe where procedures and patient encounters occur.

CPT in the Field

Mastery of CPT is how a professional medical biller and a certified medical coder earn a living, providing value to the business end of a healthcare facility’s operations. If claims are not accurately described in code, the bills will not be paid. If the bills are not paid, the healthcare facility will not be able to stay in business. Patients will suffer. Payroll and rent won’t be met.

Accredited training and certification are the keystones to a successful career in medical coding and medical billing. Armed with the knowledge of how to appropriately use CPT codes, medical billers ensure correct reimbursement in a timely fashion. The CPT codebook can be purchased by anyone, but the ability to use it correctly has to be learned. Otherwise, it is an unintelligible list of numbers followed by equally inscrutable definitions.