Current Procedural Terminology (CPT) was developed by the American Medical Association and is used to communicate medical data and practices; including patient information such symptoms, diagnoses, diseases, injuries, treatments and medical procedures.
Knowing the Prerequisites: Medical Terminology, Anatomy & Physiology
In order to become proficient in the CPT system, it's important to be able to understand, interpret and review medical-relevant documents. Since medical terminology serves as the language that's cited in the data, becoming proficient in its fundamentals (root words, prefixes, suffixes and combining forms) is necessary. Furthermore, you'll need to know basic human anatomy and physiology, so you can locate the correct code within the CPT system. Human anatomy and physiology is generally broken up into the following categories: Body Structure/Functions, Cells/Tissues/Membranes, Skeletal System, Muscular System, Nervous System, Endocrine System, Cardiovascular System, Lymphatic System, Respiratory System, Digestive System, Urinary System, and Reproductive System. A number of online cites provide diagrams, study guides, overview and assessments in these areas (see links below).
CPT Functions & Category Overview
CPT coding is the conversion of verbal descriptions of diseases, injuries and procedures into numeric or alphanumeric terms. The codes serve as a universal medical language and are used to convey records, diagnoses and procedures (required for reimbursement) clinical care, research, and instruction (www.ahima.org). The CPT system is divided into three distinct categories. Category I codes contain a five-digit code with definition, which is used to identify a service or procedure. Category II codes are supplemental tracking codes that can be used for performance measurement. Category III codes are four digits and a letter and are used for emerging technologies, services and procedures (www.ama-assn.org). CPT is also comprised of: Level I National Codes, Level II National Codes and Level III Medicare Local Codes.
Understanding the CPT Manual & Sections
The Current Procedural Terminology Manual, put forth by the American Medical Association, includes code listings which are divided into assorted divisions including: Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory and Medicine. Within these divisions there are: Section Headings, Subsections, Categories, Subcategories, Guidelines, Symbols, Colons & Semi-colons Modifiers, Appendices, Indices and Examples. Although, overwhelming, the codes and their location follow a standard progression. For example, CPT codes that fall under Pathology and Laboratory range from 80048 to 89356. If a urinalysis was done under this category, the code would range from 8100 to 81099. The range's specific details or procedures would dictate the precise number. If you were trying to locate a surgery code (10000-69999); you would have to locate that section's heading and then find the corresponding subheading to classify what type of procedure was conducted and where on the body it was performed. If it took place within the patient's Integumentary System (10040-19499) and an excision was done on a benign lesion (11400-11471), you would then have to detail where the incision was made and how big it was (www.ahima.org).
Additional Tips & Practice
Because the codes you'll encounter the most will differ according to specific areas of practice and specialty (psychiatry, immunology), it's wise to get a handle on those first. You can practice by reviewing medical documents (patient records, discharge papers, procedure documents, and more) and see how far you can get without using an encoder. Creating flashcards and your own study guide can help you better understand all CPT aspects. Since medical CPT codes are required to follow all federal, legal and insurance regulations, agencies and providers, exploring the sites of organizations that oversee coding regulations, applications and delivery systems can provide you with more information, regarding the role of standard classification systems, code development and implantation. The Joint Commission and Institute for Safe Medication Practices are two sites devoted to the above.
Serena Spinello holds two master’s degrees and is pursuing her Ph.D. in medical science. She has been a professional writer and researcher for over 10 years and is an active member of the American Medical Writers Association, Academy of Medical Educators, and the National Association of Social Workers.