HCPCS, CPTs, E&Ms, service types.
These are the terms we are going to cover today. Previously we looked at the CDM (the Charge Description Master), which operated with a basic assumption of medical codes and services. In this article, we are going to take a step deeper and breakdown the codes that translate our healthcare service offerings into patient bills and payor claims.
What is a HCPCS/CPT?
Healthcare Common Procedure Coding System (HCPCS)
HCPCS (Pronounced “Hicks-Picks”) is the standard coding system of the US healthcare system.
There are three levels of HCPCS:
Current Procedural Terminology – Procedures and Services provided by healthcare professionals (this category is also called CPTs).
National Healthcare Common Procedure Coding System – Drugs, Supplies, Equipment, and non-physician services.
Temporary Codes – Allow health care professionals to identify emerging technologies, services, and procedures.
HCPCS Type I: Current Procedural Terminology (CPT®)
HCPCS are the standard national language, and CPTs are services and procedures rendered by healthcare professionals.
There are three main categories of CPTs:
Services and Procedures – All numeric.
Tracking Outcomes – Four numbers and the letter F.
Temporary/New – Four numbers and the letter T.
There are six sub-categories of category I CPTs:
Evaluation & Management (99202–99499)
Anesthesia (00100–01999)
Surgery (10021–69990)
Radiology Procedures (70010–79999)
Pathology and Laboratory Procedures (80047–89398)
Medicine Services and Procedures (90281–99607)
HCPCS Type II: National Healthcare Common Procedure Coding System
There are 31 ranges of Level II HCPCS Codes.
Start with a letter (A-V), and then four numbers.
Used in combination with CPTs.
CPT® codes: What the provider did
HCPCS codes: What the provider used
Note: Do not forget about why the provider treated the patient with that service and those supplies. These are the ICD-10 codes.
HCPCS Type III: Temporary Codes
There are 18 categories of Level III HCPCS Codes.
2020 Example: Q0220-Q0249 – Covid-19 Infusion Therapy.
Yearly CMS publishes which codes (in tandem working with AMA) become permanent national codes.
Overview of Service Types
HCPCS Type I: Clinical Services
Aka CPT codes.
aka services, not supplies.
Evaluation & Management (99202–99499)
Anesthesia (00100–01999)
Surgery (10021–69990)
Radiology Procedures (70010–79999)
Pathology and Laboratory Procedures (80047–89398)
Medicine Services and Procedures (90281–99607)
HCPCS Type I: Evaluation & Management (E&M) CPTs
AMA Definition: “These represent services by a physician (or other health care professional) in which the provider is either evaluating or managing a patient’s health.”
Tip: If it starts with 99XXX it is an E&M, since the range on the CPT series is 99202–99499.
Currently, there are 147 CPTs that start with 99XXX. We can categorize based on service location (or rather patient type).
There are 25 categories of E&M CPTs.
The sets we look at most often in the E&M ranges are:
Office Visits:
PCPs
Urgent Cares
Outpatient Visits
Inpatient/Observation Visits
Emergency Department Visits
Critical Care Services
Patient Visit – Example 1
ED Example:
Patient arrives at ED with chest pain, patient has shortness of breath, and left arm pain. Patient gets EKG, findings are abnormal.
This patient will likely be a level 5 (99285) since they have chest pain and there is evidence of a heart attack or stroke.
Patient also had an EKG (93010) that helps determine the current condition of the patient.
We would bill out one claim for this patient’s ED visit with a 99285 + 93010.
Patient Visit – Example 2
In-Patient Example: (SIMPLE)
Patient arrives at surgery with extreme abdominal swelling and pain and results from the ED indicating they are having an appendicitis.
This patient gets an appendectomy (appendix surgery), CPT 44955.
As part of this surgery, they have to have their appendix drained, CPT 44901.
We would bill out one claim for this patient’s surgery visit with a 44955 + 44901. There would likely be other codes billed with this surgery to complete the picture. And there would be separate codes for their IP recovery.
RECAP
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