Current Procedural Terminalogy (CPT)

coding
Charge codes assigned for surgical pathology services are regulated primarily by Current Procedural
Terminology (cpt

). The CPT codes allow health care provides to connect for payment from third-
party payers (Medicare, Medicaid, and private insurance companies) about the procedures and
services rendered to the patient.
Current Procedural Terminology is a coding system developed by the American Medical Association
(AMA). CPT is presented in manual taxonomy and instructions format to convert widely accepted,
uniform descriptions of medical, surgical, and diagnostic services into five-digit numeric codes. The
manuals text is owned and maintained by AMA CPT Editorial Panel. Medicare, other government
payers, and private insurers can issue specific instructions that modify the CPT manuals guidance.
Some history
In 1965, U.S. Congress established a new Medicare program that required a uniform nomenclature
for medical and surgical services. Private insurers were also interested in a nationally accepted
nomenclature. The first edition of the Current Procedural Terminology (CPT), published in 1966, was
based on the California Relative Value Study. The third edition was published in 1973, the fourth in
1977.
Use of the CPT manual was increased in 1983 when the Health Care Financing Administration (HCFA)
incorporated the CPT codes through Health Care Common Procedural Coding System (HCPCS) and
began requiring its use for reporting of services and procedures provided to Medicare beneficiaries.
The insurance companies which administered Medicare programs across the country began shifting
from their then current coding systems to the HCPCS system. During the transition it became
obvious to many of the Medicare carriers that if they were going to have to accept CPT codes for
Medicare, they might as well accept them for all the policies they wrote. Other insurance companies
followed suit because they realized that it would be in their interest to accept CPT codes. Within
three years all insurance companies in the US began accepting, if not requiring, the use of CPT codes.
And, as of 1987 most Medicaid programs nationwide began accepting HCPCS codes. In 2000, the
U.S. Department of Health and Human Services designated CPT as national wide standard to report
medical services. According to Health Insurance Portability and Accountability Act (HIPAA), the CPT
data must be used for medical services and procedures rendered to patients by all providers,
government payers and insurers.
The new HCPCS coding system consisted (and still does) of three levels of codes. The Level I, and the
largest portion of HCPCS, is CPT. Level II national codes (HCPCS) are used by providers to code for
services, supplies, and equipment provided to Medicare patients for which no CPT codes exist.
There are three categories of medical services and procedures in the Current Terminology Procedure.
Category I encompass most physicians and laboratory services. Category I is updated annually on
January 1. Category II codes exist to monitor performance outcomes, and Category III codes are
temporary before the code is placed in the Category I. Actually, surgical pathology uses only
Category I codes.
CPT (more than 8,000 procedures listed), is the most widely used coding system for reporting
services and procedures to health insurance companies. Virtually all payers accept CPT code, while
Medicare and Medicaid require CPT codes.
The CPT manual is composed of six divisions which called sections. All codes and descriptions are
categorized. The CPT codes are arranged in numerical order in each section. CPT sections Pathology
and Laboratory have range of codes 80002-89399. The surgical pathology codes occupy a minute
portion of them (88300-88399).
CPT codes can be distinguished from other codes in that they consist of five numbers followed by a
verbal description of the procedure or service associated with the code. Insurance pays not only on
WHAT (CPT) but also WHY (ICD-9-CM).
CPT also contains numeric modifiers (two or five digits) that are to be listed after the codes which
they modify. The modifiers are predominately the billing managers realm
Most hospitals and commercial laboratories use computer dictionaries in their anatomic pathology
information system. Computer dictionary has a CPT coding module plugged into their information
module which combines clinical procedures with CPT manuals descriptors. If an institution does not
use an information system, the charge capture system is carried out manually, but using CPT codes.
The Medicare Correct Coding and Payment Manual for Procedure and Services uses the Payment
Computation formula. According to the Manual, the first step is to assign the initial code using the
CPT manual. If the initial CPT/HCPCS code were chosen incorrectly, everything goes wrong. These
materials concentrate on the initial CPT code.
CPT coding might disappear in the USA with changes in health care organization. However, in the
foreseeable future it will remain as a tool for clarification of financial relationships between
healthcare providers and payers.