Current Procedural Terminology (CPT)

CPT is an abbreviation for Current Procedural Terminology, which was first developed and published by the American Medical Association (AMA) in 1966. CPT has three categories: Category I are codes that explain a procedure or service. Category II is codes that are a set of optional tracking codes, which are developed mainly for performance and measurement. These codes are mostly included in an evaluation and management (E/M) service. Category III is codes that are temporary codes for developing technologies, services, and procedures. These codes are used mainly for data collection purposes. There are eight sections in the CPT codebook. The sections are (a) evaluation and management, (b) anesthesia, (c) surgery, (d) radiology, (e) pathology and

A new patient is someone who has not received any services from the provider or another provider of the same specialty or subspecialty within the past three years. An established patient is someone who has seen the provider or another provider in the practice who has the same specialty within the past three years. A referral is a handover of the complete care or specific portion of patient care from one physician to another. A consultation is when another physician, at the request of the patient’s physician examines the patient and gives an opinion. There are three key components for determining an E/M code such as the extent of the history documented, the extent of the examination documented, and the complexity of the medical decision making

Modifiers are used with CPT codes to denote that a service or procedure has been altered by a specific situation but not changed in its definition. Add-on codes are the codes used in addition to describing a procedure or service. Anesthesia codes require a physical status modifier and time spent providing the anesthesia service. Anesthesia time begins when the patient is being prepared for anesthesia and ends when the patient is in postoperative care. A separate procedure is considered as separate when the procedure is done independently, unrelated, or distinct from other procedures. A surgical package includes the evaluation and management encounter on the date immediately before or on the date of surgery or subsequent to the decision of surgery, the surgery, anesthesia, postoperative care and follow-up. Radiology codes include two components such as technical and professional. Some examples of technical components are taking an x-ray, injection of contrast material, placement of the catheter. One example of the professional component is an interpretation of x-ray by a physician. Pathology and laboratory codes include test ordering, taking the sample, actual test and analyzing and reporting the results of the test. In the medicine section of CPT, the immunization needs two codes including the administration