Current Procedural Terminology codes, or CPT codes, are a set of medical codes used to describe the procedures and services that clinics and hospitals perform. Created by the American Medical Association in the mid-1960s, CPT codes are used in the United States for documentation, billing, and research purposes.
In this article, we will give you a better understanding of the structure of each CPT code, their usage in the broader American healthcare system, and how they are updated. More importantly, we will explore how CPT codes and RVUs are two separate tools premeds and medical students must be aware of.
What Are CPT Codes?
CPT codes are five-digit numeric codes that are used to report medical, surgical, and diagnostic procedures to other physicians, health insurance companies, and accreditation organizations.
A CPT code will structurally have three parts: the numeric code, modifier, and description.
The numeric code is the specific identifier for a unique medical procedure and is found at the start of each CPT code.
Next is the modifier, which is an additional one or two digits that provide more information about the procedure. For example, the modifier will tell you if the service was performed on the left side of the patient, the right side, or if it was performed bilaterally.
Last is the description, which is exactly what it sounds like. It’s a very brief description of what the procedure is, assisting in the searchability of CPT codes and ensuring the correct codes are selected.
Additionally, there are three main types, called Categories, of CPT codes.
Category I are by far the most commonly used CPT codes as they represent services that are consistent with medical practice and are used for billing purposes. There are six sections to Category I that correlate to a specific area of medical practice.
- Evaluation and Management (E/M): Codes 99201–99499 (e.g., 99213 – Office or other outpatient visit for an established patient).
- Anesthesia: Codes 00100–01999 (e.g., 00100 – Anesthesia for procedures on the integumentary system on the extremities, anterior trunk, and perineum).
- Surgery: Codes 10021–69990 (e.g., 25000 – Incision, extensor tendon sheath, wrist).
- Radiology: Codes 70010–79999 (e.g., 71020 – Radiologic examination, chest, two views, frontal and lateral).
- Pathology and Laboratory: Codes 80047–89398 (e.g., 80050 – General health panel).
- Medicine: Codes 90281–99607 (e.g., 93000 – Electrocardiogram with at least 12 leads; with interpretation and report).
Category II are supplementary codes used for performance measurement and quality reporting, and as such, they are not used for billing. This category is likely the most relevant for medical students as many of these codes can be searched to find trends in patient outcomes, which can then be turned into a research paper.
Category III are used for emerging, novel technologies and services that are yet to be established as Category I codes. Again, this inherently makes this category of CPT codes highly relevant for medical student research, as these codes make it easy to track the outcomes for experimental treatments and technologies.
CPT Codes on a Medical Bill
Because each medical service has its own CPT code, it becomes easy for hospitals and clinics to assign each CPT a “Relative Value Unit.” When you multiply the RVUs with the current reimbursement rate, you can get an approximation of how much the hospital was paid for the services they provided you.
If you would like to see an example of how a medical bill is turned into dollars, read this guide that goes into a great deal more depth about RVUs and how they are calculated.
CPT Code Examples
Here are some of the most commonly used CPT codes:
Evaluation and Management (E/M)
- 99213: Office or other outpatient visit for the evaluation and management of an established patient, typically requiring a low to moderate level of medical decision making.
- 99214: Office or other outpatient visit for the evaluation and management of an established patient, typically requiring a moderate level of medical decision making.
- 99203: Office or other outpatient visit for the evaluation and management of a new patient, typically requiring a low to moderate level of medical decision making.
- 99204: Office or other outpatient visit for the evaluation and management of a new patient, typically requiring a moderate level of medical decision making.
Preventive Medicine
- 99396: Periodic comprehensive preventive medicine reevaluation and management of an individual, 40-64 years.
- 99395: Periodic comprehensive preventive medicine reevaluation and management of an individual, 18-39 years.
- 99391: Periodic comprehensive preventive medicine reevaluation and management of an individual infant (age younger than 1 year).
Laboratory Tests
- 80050: General health panel (includes comprehensive metabolic panel, thyroid stimulating hormone test, and complete blood count with automated differential).
- 81002: Urinalysis by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy.
- 85025: Complete blood count (CBC) with automated differential white blood cell count.
Radiology
- 71020: Radiologic examination, chest; two views, frontal and lateral.
- 74177: Computed tomography, abdomen and pelvis; with contrast material.
Medicine
- 93000: Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report.
- 90471: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid).
- 90715: Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use.
Minor Procedures
- 12001: Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet); 2.5 cm or less.
- 17110: Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement) of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions.
Understanding How Doctors Are Paid
Understanding how doctors are paid is crucial for medical students as it directly impacts their future careers and patient care. A comprehensive knowledge of the medical reimbursement system, including CPT codes and RVUs, equips you with the ability to navigate the complex financial landscape of the American healthcare system.
This understanding ensures you can advocate for fair compensation, manage practice finances effectively, and make informed decisions about your career path, whether in private practice, hospitals, or academic settings.
If you’re interested in learning how different specialties operate in academic, private practice, and community settings, make sure to check out our So You Want to Be series, which breaks down the many different specialties and career paths in medicine.
If you have a suggestion for a specialty or healthcare career you’d like us to cover, leave a comment below.
