Current Procedural Terminology (CPT) Code Brief

Current Procedural Terminology (CPT) is a code set that is established and maintained by the American Medical Association (AMA). This large and comprehensive code is used to describe tests, surgeries, evaluations, and any other medical procedure performed by a health care provider on a patient. A health care provider is defined as “an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.” (American Medical Association, CPT 2016, Introduction, p. xii)

CPT codes are a crucial part of the medical billing process as they tell the insurance payer what procedures were performed by the provider and what they would like to be reimbursed for. Together with ICD codes, CPT codes create a complete picture of the medical process for the insurance payer.  “The patient arrived with these symptoms (as represented by ICD code) and we performed these procedures (as represented by the CPT code).” Additionally, CPT codes can be used to measure health data, value, performance, and efficiency.

The codes are divided into three distinct categories:

• Category I: Describes most of the procedures performed within the in- and outpatient settings.
  • Evaluation and Management
  • Anesthesiology
  • Surgery
  • Radiology
  • Pathology and Laboratory
  • Medicine

• Category II: Used primarily for performance management and future care (optional).
• Category III: Temporary codes that describe new technologies, services, and procedures. They are useful for data collection and utilization tracking.

There is a specific procedure in place to add, delete, or revise a code. “Medical specialty societies, individual physicians, hospitals, third-party payers, and other interested parties may submit applications for changes to CPT for consideration by the editorial panel.” (American Medical Association).  These applications can have one of four outcomes:

• Addition of new code or revision of existing code
• Referral for further study
• Postponement
• Rejection

Of note, with Category III codes being considered emerging services, they are often converted to Category I codes through a similar application process to demonstrate that the Category I code criteria has been met.

Learn More

For more information on CPT codes, click here.

For more information on National DPP-specific CPT codes, see the CPT Code Guidance document created by the American Medical Association (AMA).