Health and wellness professionals who bill insurance or third-party payers directly, or provide Superbills to clients, need to be well-versed in Current Procedural Terminology (CPT) codes.

Accurate use of these codes is critical for successful billing and reimbursement. These codes are also important for documenting healthcare services provided to patients.

Even wellness pros who are paid directly by clients may need to be up to speed on CPT codes. That’s because local regulations and licensing boards may have specific requirements to use CPT codes for the purposes of record-keeping and documentation. 

With CPT codes changing yearly, staying up to date is critical. Keep reading for your complete CPT code primer, including how they’re structured, who maintains them, how they differ from other medical codes, and where to find the most up-to-date codes.

Key Takeaways

• CPT codes are used to report surgical and medical procedures and services and diagnostic services. They are critical for accurate reporting and reimbursement.
• There are three categories of CPT codes plus modifiers to provide additional information. CPT codes are different from ICD-10 codes and have some overlap with HCPCS codes.
• The American Medical Association's CPT Editorial Panel is responsible for revising, updating, and modifying CPT codes, descriptors, rules and guidelines.

Understanding Current Procedural Terminology (CPT) Codes: The Basics

CPT codes are a standardized set of codes used to describe medical, surgical, and diagnostic services provided to patients in the U.S. healthcare system.

Developed and maintained by the American Medical Association (AMA), CPT codes are essential for billing and reimbursement through health insurance providers. 

For health and wellness practitioners who operate within the traditional U.S. reimbursement and billing system, these codes can cover services like evaluations, consultations, therapeutic interventions, and more.

CPT Code Structure

A CPT code typically consists of three parts:

1. Numeric Code. CPT codes begin with a five-digit numeric code. This code is the core identifier for a specific medical procedure or service.
2. Modifier. Some CPT codes may include one or more two-digit modifiers. Modifiers provide additional information about the service or procedure performed. For example, modifiers can indicate that a procedure was performed on the left or right side of the body or that multiple procedures were performed during the same session.
3. Description. Each CPT code is associated with a description that explains what the code represents. This allows healthcare providers and payers to understand the nature of any service provided.

CPT vs. ICD Codes

In the simplest terms, CPT codes describe things like procedures and services and ICD codes describe diagnoses and conditions. 

ICD stands for International Statistical Classification of Diseases. ICD-10 codes are maintained and updated by the World Health Organization (WHO) and used around the globe for the purposes of health recording and statistics.

In the U.S. ICD-10-CM codes are standard, where the CM stands for "Clinical Modification." These codes include additional clinical details and specificity, making them more suitable for clinical and billing purposes within the U.S. healthcare system.

Types of CPT Codes: A Closer Look

CPT codes are divided into three main categories: Category I, II and III.

Category I CPT Codes

Category I codes are the most commonly used CPT codes for the purposes of billing and documentation. They describe a vast array of medical procedures, diagnostic tests, office visits, and treatments relevant to healthcare providers and wellness professionals. 

For example, CPT code 97802 is a Category I code that represents "Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes." Registered dietitians and nutrition professionals use this code to bill for their services when providing individualized medical nutrition therapy to patients.

Category II CPT Codes

Category II codes are supplementary codes used for performance measurement and quality reporting. They are not used for billing. Rather, these codes help with data collection for quality reporting and research.

While wellness professionals won’t commonly use Category II codes in their day-to-day practice, they may use them in situations where they are participating in quality improvement initiatives or research. 

For example, Category II CPT code 3008F is used for the documentation of body mass index (BMI) in adults. Specifically, it is used to indicate that healthcare providers have documented an adult patient's BMI as part of the patient's medical record. 

Category III CPT Codes

Category III codes are temporary codes used with emerging technologies and services that don’t yet have established Category I codes.

These codes allow providers, payers, and researchers to track the use of and outcomes related to new and experimental treatments or technologies. They are often used in clinical trials or when new procedures are in the early stages of adoption.

It’s unlikely that wellness pros would use Category III codes, but it could be possible. For example, someone who is involved in clinical research or trials that involve novel wellness interventions or technologies might use these codes to document and track the specific procedures or services they are providing as part of the study.

The Role of Medical Coders in CPT Coding

Although health and wellness practitioners may engage in coding-related tasks when billing for their services, they are not considered full-fledged medical coders. 

Medical coding is a distinct profession with its own formal education, training, and certification requirements. The role specifically involves accurately assigning codes to care services and procedures. 

Challenges Faced by Medical Coders

Medical coding professionals must continuously update their skills and knowledge to ensure accurate coding and compliance with healthcare regulations.

• Regulations are always changing. Medical coders must keep up with evolving healthcare regulations and changes in payer policies and compliance requirements.
• Data security and privacy. The Health Insurance Portability and Accountability Act (HIPAA) regulations mandate protecting the security and privacy of patient health information. Medical coders must comply with the Health Insurance Portability and Accountability Act .
• Audits and compliance. Medical coders are under the constant pressure that insurance companies or government agencies can perform a coding audit at any time to ensure accuracy and compliance with billing and coding standards.

Importance of Accurate Coding for Medical Procedures

Accurate coding means proper reimbursement. When codes are incorrect or lack specificity, it can lead to underpayment, delayed payments, or even non-payment by insurance companies. 

Although getting paid correctly and on time matters a lot, it’s important to know that coding errors can also impact patient care, legal compliance, data quality, research, and healthcare quality improvement. It plays a central role in the integrity and effectiveness of healthcare providers and the system as a whole.

Category I CPT codes are updated annually and effective for use on January 1 of a new calendar year. The updates may include the addition of new codes, revisions to existing codes, and deletions of obsolete codes. Staying current with these changes will help with accurate coding.

CPT Modifiers: Adding Context to Codes

Modifiers are added to Current Procedural Terminology codes to provide additional information. They indicate that a service or procedure performed has been altered, yet the definition of the service hasn’t changed. 

CPT modifiers are added to the end of a CPT code with a hyphen. When using more than one modifier, list the modifier that most impacts reimbursement first. The informational modifier can go second. 

Types of CPT Modifiers

Modifiers are typically either composed of two digits or two alphanumeric characters. 

• Two-digit modifiers consist of two numbers. They provide specific information about the service or procedure, such as indicating that a separate and distinct service was performed, or that a service was repeated.For example, if a dietitian used CPT code 97803 to get reimbursed for nutrition counseling, but she provided the service via Telehealth, then she would add the modifier code 95 like so: 97803-95.  
• Alphanumeric modifiers use a combination of letters and numbers. One well-known alphanumeric modifier is "-LT" (left side) and "-RT" (right side), used to specify whether a procedure was performed on the left or right side of the body.
• HCPCS (Healthcare Common Procedure Coding System) Level II modifiers aren’t technically CPT modifiers. They may include alphanumeric characters to convey specific information about services, equipment, and supplies. We’ll get into the distinction between CPT and HCPCS a little later in this article. 

Where to Find Current CPT Codes

There are a variety of resources that can help with finding current CPT codes. 

• The American Academy of Professional Coders (AAPC) sells several different CPT books. They also power a platform called Codify that offers a subscription-based look-up tool. 
• The American Medical Association offers links to various coding resources. And they share monthly updates on the CPT code set and related industry news to those who subscribe to their newsletter.
• The Centers for Medicare & Medicaid Services (CMS) offers a free search (CPT code lookup) for RVU (Relative Value Units) for every CPT code. You can also request a CPT/RVU Data File license from the American Medical Association if you want to import codes and descriptions into existing claims and medical billing systems.

The CPT Code Approval Process

The CPT Editorial Panel is composed of 21 members who are responsible for maintaining the CPT code set.

The CPT Editorial Panel is authorized by the American Medical Association Board of Trustees to revise, update, or modify CPT codes, descriptors, rules and guidelines. 

The CPT Editorial Panel meets three times a year and addresses over 200 major topics, each reviewed and discussed with careful consideration.

Criteria for CPT Code Applications

The American Medical Association has set out specific guidelines for adding, deleting, or modifying codes through the CPT Editorial Panel.

There are specific applications to use depending on the nature of the request. The AMA has also outlined the CPT code process in great detail. Here are a few highlights:

• Many different entities can submit applications for changes to CPT codes, including medical specialty societies, individual physicians, hospitals, and third-party payers.
• All requests to revise CPT codes are reviewed by AMA staff. If they believe the CPT Editorial Panel has already addressed a request, they let the requesting party know. If the request represents a new direction then the application is referred to members of the CPT Advisory Committee for consideration and comments.
• After the Advisory Committee consideration, the AMA staff prepare an agenda item that includes the application, compiled CPT Advisor comments and a ballot for decision by the CPT Editorial Panel. Once the CPT Editorial Panel has taken an action and preliminarily approved the minutes of the meeting, AMA staff informs the applicant of the outcome.
• After going through the above process, there are four possible outcomes: a new CPT code is added, a request is referred for further study, consideration is postponed to a future meeting, or the request is rejected. 

CPT Codes vs. HCPCS Codes: Key Differences

The American Medical Association first published CPT codes back in 1966, when they were mainly used for coding surgical procedures. In 1983, the CMS adopted CPT codes as part of HCPCS. 

The HCPCS code set is divided into two principal subsystems:

1. Level I of the HCPCS is the same as the CPT code set. These codes primarily describe medical services and procedures provided by physicians and other healthcare providers in clinical and outpatient settings.
2. Level II of the HCPCS is a set of codes distinct from CPT codes. They are used for a broader range of non-physician services and supplies, including durable medical equipment (DME), ambulance services, and certain outpatient procedures. They give providers and payers a standardized language for communication and reimbursement.

Master CPT Codes to Drive Revenue and Elevate Care

Understanding the ins and outs of CPT codes can be a valuable skill for health and wellness practitioners.

Yes, getting CPT codes right the first time ensures you get reimbursed accurately and on time when dealing with insurance of third-party payers. The codes also represent a standardized way to describe and document the specific healthcare services you provide. Keeping comprehensive records supports continuity of care and can be valuable for tracking patient progress over time.

Learn more about the features built into Practice Better to help automate insurance billing – from setting up your insurance billing profile to storing CPT and custom codes into the platform so they are available for use at any time.

Frequently Asked Questions

What are 5 common CPT codes?

The CPT codes that a wellness practitioner uses frequently when billing will depend on the nature of services provided. Here are five Five CPT codes that could be commonly used in a wellness practice. 

CPT code 99401 - Preventive Medicine, Individual Counseling. Wellness professionals might use this code for counseling sessions related to lifestyle modifications, such as nutrition, exercise, or stress management.

CPT code 99078 - Group Health Education. Wellness professionals who conduct group workshops or classes on various health and wellness topics (e.g., diabetic teaching or a prenatal nutrition class for expectant mothers) might use this code to document those educational sessions.

CPT code G0438 - Annual wellness visit (AWV), includes personalized prevention plan of service (PPPS), initial visit. CMS allows for AWV coverage for a medical professional or team under a physician’s supervision, for example registered dietitians or health educators. 

CPT code G0439 - AWV, includes PPPS, subsequent visit. This code is used for AWV visits following the initial one. 

CPT code 97802 - Medical Nutrition Therapy Procedure. A dietitian could use this code for an initial individual, face-to-face assessment and intervention with a client.

How do I look up CPT codes?

The Centers for Medicare & Medicaid Services (CMS) offers a free search (CPT code lookup) for RVU (Relative Value Units) for every CPT code. You can also request a CPT/RVU Data File license from the AMA if you want to import codes and descriptions into existing claims and medical billing systems.

How many CPT codes are there?

According to the AMA, the 2023 CPT code set includes 10,969 codes that describe the medical procedures and services available to patients.

What are CPT 4 codes used for?

CPT 4 is another name for the set of CPT codes published by the AMA for reporting medical procedures and services. It includes the Category I, II, and III CPT codes outlined in the above article.

What is the structure of CPT codes?

CPT codes are five digits and are either numeric or alphanumeric. Each has a descriptor to help users understand their purpose. They are organized into three categories: Category I (most commonly used to report services and procedures), Category II (tracking codes for performance management) and Category III (temporary codes for emerging or experimental activities).

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