Medical Billing and Coding Certification

As the healthcare and insurance industries require accuracy and compliance with complex regulations, medical billers and coders are held to these same standards. Certification is a way of showing your dedication and expertise. While you may not necessarily need a medical coding certification to get an entry-level job, you will find that your opportunities for career advancement multiply once you’ve achieved such a distinction. You’ll be more likely to demand a higher salary, earn a position of leadership, and perform different kinds of work.

Certifications are available for various professionals that work in the medical records and health information field. They’re also offered by a number of different organizations. As you plan your career goals, do your research to get the basic facts about certification and opportunities for specialization. Then consider a timeline for gathering the education, training, and experience that will help you pass the certification exam that’s right for you.

Explore Certification and Continuing Education

Important information about the types of certification available for medical billers and coders is explained in the following section.

AAPC certification

The most well-known agency that administers and oversees certifications for medical billers is The American Association of Professional Coders (AAPC). It also tracks required continuing education units through a system that records the knowledge you’ve gained from classes, conferences, seminars, and other educational opportunities on a variety of topics. The AAPC offers general certifications, as well as 21 specialty certifications.

General certifications: The main certifications are the Certified Professional Coder (CPC), Certified Professional Coder – Hospital Outpatient (CPC-H), and Certified Professional Coder – Payer (CPC-P).

Specialty-specific coding certifications: You can choose to focus on a particular area in the healthcare industry and pursue certification to demonstrate expertise in that area. These specialty certifications emphasize coding problems related to those fields, as well as professional requirements to work in these areas. You don’t necessarily need to acquire a general coding certification to obtain one of these specialty certifications (see the AAPC website for accurate and up-to-date information about specific requirements), but you will find that a variety of certifications make you more versatile and marketable to employers.

Use the following list to discover the wide variety of medical billing and coding jobs that are available across all sectors of the healthcare industry.

• Ambulatory Surgical Center (CASCC™): Also known as outpatient surgery, ambulatory surgical centers (or same-day surgery) perform medical procedures that do not require overnight stay. This specialization requires knowledge of surgical procedures. You’ll interpret notes provided by medical professionals and convert them into medical codes that accurately represent highly specific information. There are no prerequisites for this certification exam (other than AAPC membership,) which is designed to simulate the transcription of case notes.
• Anesthesia and Pain Management (CANPC™): Anesthesiologists administer drugs to patients for their symptoms or as part of their surgical procedures. You’ll be expected to know how to choose the right CPT codes for different procedures, as well as how to use modifiers for anesthesia cases. You’ll also be tested on determining time units and total units for cases that require anesthesia.
• Cardiology (CCC™): Heart health is a growing sector of the healthcare industry. Passing the examination for this certification demonstrates that you have a knowledge of cardiological surgical practices and equipment, such as stents and pacemakers. Because heart health is often related to other vascular procedures and has associated insurance regulations, this coding specialization presents unique challenges. You’ll be expected to know how to code for surgical procedures such as catheterization, placement of pacemakers, and peripheral vascular procedures.
• Cardiovascular and Thoracic Surgery (CCVTC™): This certification demonstrates that you possess knowledge of the treatment, equipment, and testing procedures associated with cardiovascular and thoracic surgery (surgeries performed on the heart, lungs, and greater vessels in the chest). You’ll need to possess both technical knowledge of Medicare billing rules and medical knowledge of the heart and circulatory system.
• Chiropractic (CCPC™): Chiropractic services involve manually adjusting a patient’s spinal system, which is considered complementary or alternative medicine. Medical billers and coders working alongside chiropractic professionals need to be able to navigate the specific ways that insurance companies reimburse these practitioners. You’ll also need to be aware of its diagnostic procedures in this field.
• Dermatology (CPCD™): Dermatologists diagnose and treat diseases related to the skin. Billers and coders working with dermatologists need to have knowledge of these skin conditions and related treatments. This means you’ll have to familiarize yourself with the anatomy of human skin and the classification of its disorders. You should also be knowledgeable of procedures such as debridement, lesion excisions, and flaps.
• Emergency Department (CEDC™): Billers and coders who have this specialized certification have obtained proof of their expertise in accident and trauma codes, as well as some knowledge of pain management and sedative treatments. Because this dynamic subfield requires you to work quickly on your feet, you’ll need to be very familiar with associated codes.
• Evaluation and Management (CEMC™): The healthcare industry relies upon a system of classifying codes not only to bill insurance companies, but also to track health information for planning purposes. Coding professionals in this specialization work to manage the costs incurred by medical offices and hospitals and help ensure quality treatment. As you’ll be tested on both billing regulations and your coding proficiency, you’ll do best after earning broad professional experience in the field.
• Family Practice (CFPC™): There’s a variety of health information that billers and coders must manage in family practice settings. You’ll need to understand general insurance reimbursement regulations and know how to accurately sequence codes when several procedures are performed together (as in an annual checkup.) You should also have general knowledge of pediatric medicine.
• Gastroenterology (CGIC™): Gastroenterology is the field that treats gastric disorders. You’ll need to be knowledgeable about each abdominal organ in order to code very specific conditions and procedures. You can expect to learn codes used for procedures such as ERCPs, colonoscopies, and esophageal dilations.
• General Surgery (CGSC™): This certification demonstrates your expertise in the field of billing and coding surgical procedures. With a variety of surgeries performed each day, you’ll be tasked with quickly and accurately transcribing operating room notes into codes. You’ll need to also understand the set of rules regarding private and public insurance reimbursement. The AAPC recommends that you complete this certification after having plenty of work experience as this exam is based on simulated coding scenarios.
• Hematology and Oncology (CHONC™): This certification signifies that you have an expertise in coding issues related to the treatment of cancers and blood disorders. These can include bone marrow treatments, chemotherapy and hydration, and blood tests. These procedures are particularly complex, requiring that billers sequence on-going care that requires a number of treatments. Insurance providers also have stipulations about compensation for surgeries and drug-based forms of disease treatment and management.
• Internal Medicine (CIMC™): Internal medicine is the treatment and prevention of adult diseases. You’ll have to be comfortable using codes to classify vaccinations, blood draws, and other minor procedures and surgeries. This specialty requires high attention to detail and accuracy, and your best preparation for the exam is real-world experience.
• Obstetrics Gynecology (COBGC™): This medical coding specialty requires training and experience working in women’s health. To manage the health records and information in an OB/GYN office, you’ll need to be familiar with the procedures used in prepartum, postpartum, and childbirth care. You’ll have to stay up-to-date on gynecological concerns and complex sets of regulations maintained by insurance providers.
• Orthopaedic Surgery (COSC™): Coding orthopaedic surgeries requires a basic familiarity of the anatomy of the human skeletal system and its functions, as well as its related surgeries. These include fracture repairs, spinal surgeries, and other types of procedures for a variety of disorders. You’ll also need to demonstrate knowledge of insurance and billing regulations, including Medicare rules regarding shared visits, teaching situations, and consultations.
• Otolaryngology (CENTC™): Billters who work in the ENT specialty (ear, nose, and throat) have to learn the diagnostic procedures and treatments used by ENT specialists, including nasopharyngoscopies, laryngoscopies, and sinus surgeries, The AAPC recommends having work experience in this field because it requires a familiarity with insurance regulations, Medicare, and billing procedures for common surgeries and procedures.
• Pediatrics (CPEDC™): Achieving this professional certification demonstrates that you have training and experience managing the health information of children. You will need to possess general knowledge of pediatric medicine, as well as common procedures (like immunizations.) Pediatric care also requires knowledge of a wide range of treatments, many including multiple procedures or visits. The examination for this certification is based on sample doctor’s notes, so it’s a great advantage to have professional experience.
• Plastics and Reconstructive Surgery (CPRC™): Coding procedures for this field of medicine can be complex because of the highly specific kinds of procedures and surgeries performed. Because this field is also the site of elective and cosmetic procedures, you’ll need to organize data accurately for patients who are undergoing restorative surgeries so their insurers can cover their expenses. Medical coders who have experience working with plastic surgeons are more likely to succeed on this certification examination.
• Rheumatology (CRHC™): Rheumatology is the study of the treatment of joint disorders, such as arthritis. Medical billers and coders who earn this certification demonstrate general knowledge of the procedures, treatments, and medical devices and equipment used in patient care. You will also need to have an understanding of Medicare and other forms of public and private insurance billing procedures. Rheumatologists work with patients over multiple visits, and treatment can be extensive, which requires rheumatology coders to keep track of repeat treatments.
• Surgical Foot and Ankle (CSFAC™): To earn this certification, you’ll have to develop knowledge of common foot and ankle problems, as well as their associated medical treatment options and equipment. You’ll have to turn doctor’s notes into codes that accurately convey the forms of treatment provided, and know the ins and outs of Medicare and insurance billing. The AAPC recommends that you have significant clinical experience as a coder in this subfield before taking the certification examination.
• Urology (CUC™): Medical coders working with urologists must develop an understanding of urinary tract issues for patients of both genders, as well as knowledge of male reproductive health issues. If you choose to specialize in this subfield of medicine, you’ll need to accurately code ancillary procedures performed in a urologists’ offices, such as injections and urinalysis. You’ll also have to be familiar with codes for procedures performed in hospitals, such as biopsies, cystoscopies, and prostatectomies.

AMBA certification

The American Medical Billing Association (AMBA) confers the title of Certified Medical Reimbursement Specialist to qualified individuals who pass its certification exam. AMBA also offers a certificate program that teaches medical terminology and ICD-9, ICD-10, CPT, and HCPCS standards for coding medical procedures. You’ll also learn about state and federal regulations, as well as insurance company policies and practices.

AMBA doesn’t recommend taking the exam unless you have on-the-job medical experience, or some other education in medical billing and coding. Continuing education and membership to the organization are also requirements of this certification.

AHIMA certification

The American Health Information Management Association (AHIMA) offers several general medical coding certifications, which demonstrate the proficiency and accuracy required to work in hospitals, clinics, nursing homes, care centers, and private coding businesses.

Certified Coding Assistant (CCA): This is the general-purpose certification for professional coders. The exam requires a high school diploma, but the association encourages medical coding experience or training. AHIMA also requires 20 continuing education units biannually, as well as a fee to remain certified.

Certified Coding Specialist (CCS): This certification is for coders who use their coding skills in a clinical environment, like large hospitals and research institutions. This designation requiresspecialized training and/or experience, and you’ll need to brush up on your accuracy and proficiency with code systems in order to pass the exam. You’ll also need 20 units of continuing education and a fee to remain certified.

Certified Coding Specialist – Physician-Based (CCS-P): This certification program emphasizes the coding used in physicians’ offices and private practice work environments. AHIMA recommends that you’ve had some combination of work experience or education in coding or managing health records and health information. Like the other AHIMA certifications, this also requires 20 continuing education units every other year (which can be earned from a variety of sources, so check the website for details.)

Pass the AAPC Certified Professional Coder Examination

The AAPC offers twenty-one specialty examinations in medical specialties, such as cardiology and pediatrics, which you can take without earning a CPC or other certification. These exams are conducted in the same way as the CPC exams, but the content can vary slightly. Take a look at the AAPC’s list of specialty credentials to see what coding and other topics you will need to study.

Planning for the Exam

As noted above, the AAPC offers three main medical coding certifications and a number of specialized additional certifications, all of which are earned by examination. All of these examinations are multiple-choice based in medical coding, with some access to a medical coding manual allowed. In addition, the CPC-P exam includes questions on health insurance reimbursement.

All of AAPC’s exams are structured in a similar way: 150 multiple-choice questions, with the exam proctored at a specific location. The subjects of those questions vary; a CPC exam covers most topics in a general sense, while the other exams get increasingly focused on specific skills. All their exams provide you with five hours and forty minutes to finish, as well as providing you with an opportunity to retake the exam once at no additional cost.

AAPC charges a set fee for each of their examinations, which includes membership in the group – $300, or $260 if you have joined AAPC as a student. There is no formal educational requirement, although AAPC recommends that you earn an associate’s degree. You will also need to have two years of experience as a medical biller and coder to be fully certified. However, if you complete the exam without this work experience, you will still receive certification as a coding apprentice (CPC-A, CPC-P-A, etc.) and will earn your full credential as long as you work in the field and complete continuing education.

When you arrive at the exam site, you will be permitted to bring coding manuals with you. Here’s what you can bring:

• A CPT book (AMA standard or professional edition); no other publisher’s work is allowed.
• An ICD-9-CM codebook of your choice.
• An HCPCS Level II codebook of your choice.
• Officially published corrections to any errors in the above books.
• For specialty exams only, relevant anatomical charts and sample worksheets for the specific field you are testing on; check the AAPC site for full details.

The questions in the exam are structured so that these books, as well as reasoning and understanding of medical terminology, anatomy and physiology, will permit you to succeed.

You will also need to continue studying in order to keep your certification, along with remaining a dues-paying member of AAPC. You will be expected to complete 36 Continuing Education Units (CEUs) every two years. This is less demanding than it may seem; you can earn a CEU each month by completing an small test in AAPC’s journal, and workshops, online webinars and conferences give you plenty of opportunities to make up the difference.

Preparing for the Exam

AAPC offers a range of exam preparation products, and there is a great deal of material on medical billing and coding available at bookstores. What’s more, you may already be studying medical billing and coding as well as related topics in formal courses at a school or other institution. Here are some tips that may help you prepare more effectively, as well as deal with other problems leading up to your certification exam.

• If you’re stressed by the prospect of an expensive exam, remember that your payment comes with one free retest. AAPC will provide you with a full report of how you performed, including exact scores and notation of areas where you need to focus your studies. It may be helpful to think of your first try as practice.
• Remember that you are permitted to bring in codebooks; you will not need to memorize the entire coding system you are being tested on, but instead you will need to know how to quickly and efficiently find out the codes you need. Focus your practice on learning to look up codes quickly and accurately, as well as on medical terminology.
• A powerful way to study uses flash cards. Write down the information you are studying on a series of them, and go through the entire stack. If you get one right, place it in the “once weekly” stack; if you get it wrong, place it in the “once daily” stack. Review the “once daily” stack daily, moving correct answers into the “once weekly” stack, and do the same for the “once weekly” stack. This combines regular review with a focus on what you truly need to cover.

Study Guides

These resources can help you prepare yourself for medical billing and coding certification. Some of these are unofficial and others are produced by the AAPC or other professional groups.

• Quizlet: Medical Billing and Coding – This resource provides you with free, student-made online “quizlets”. There is no cost for them, and you can be certain they were made to address genuine student needs.
• ICD9.chrisendres.com – A free and searchable guide to ICD-9’s code standards, which are the primary topic of your certification exams.
• Step-by-Step Medical Coding (2013 edition) – A guide to understanding medical coding by a veteran in the field. The latest update to a long series of yearly issues; earlier editions are still largely valid, although you should look up, and keep in mind, what changes have taken place in coding practice.
• Official CPC Certification Study Guide – Published by the AAPC and written by the same panel that writes the CPC exam, you can be certain this guide will tell you what you need to know. It includes sample questions of all sorts, a specially prepared study guide, and a series of practical examples.

Sample Tests

Taking practice examinations can help you find your own weak spots for further study, as well as having benefits as a learning practice in its own right. These are some sources for sample medical coding and billing tests, which will let you test your learning without pressure and at little or no cost.

• Ritecode.com: Medical Coding Consultants – These training specialists provide a wealth of resources on the AAPC certification exam and other medical coding topics. Look for the light blue entries to find the free resources.
• Career Coders: Test your Knowledge – These sample questions, provided by a medical billing and coding instructional company, let you test your knowledge in specific fields, such as ICD-9, Medicare/Medicaid, and medical terminology.
• AAPC – Online Practice Exams – AAPC offers a series of online practice exams in all of their certification, providing you with quick feedback, detailed explanations of the reasoning behind various questions’ answers, and as many retakes as you like. They are only available for a fee, although you will get a substantial discount with AAPC membership.

Running Your Own Medical Billing and Coding Service

Explore a Day in the Life of a Medical Biller and Coder

Any time a medical service is provided, whether it’s a routine checkup or a major surgery, information about that service is recorded and given to the medical billing and coding specialist. A doctor gives the medical biller and coder procedure documentation of the services provided, which the biller and coder must then translate into the proper code. Medical billing and coding specialists are responsible for correctly coding the diagnoses and procedures performed by the healthcare provider. This requires a thorough knowledge of both ICD-9-CM codes and ICD-10-CM codes for diagnostics, and CPT codes for procedures.

A procedure document includes relevant information like the date of the procedure, the patient’s name, and his or her date of birth. More importantly, a procedure document includes the doctor’s diagnosis and the procedure performed. For example, a doctor may provide documentation of a mole removed from the torso of a patient via cryoablation (essentially, freezing the mole). The medical biller and coder would look at the procedure documentation and decide which codes correspond to the diagnosis and procedure listed. In the case of this example, a coder would select the CPT code 11710 (destruction of benign lesions or skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) for the procedure, and the ICD-9-CM code 216.5 (benign neoplasm of skin of trunk, except scrotum) for the diagnosis.

The bulk of the medical coding portion of the billing process involves turning procedure reports into correct medical code, then entering it into the system for the claims process. Medical coders spend their day taking procedure documentation, looking up the proper codes, and entering that information into their claims software. Most medical coding is relatively straightforward (for example, the CPT code 99213 corresponds to a routine visit to the doctor’s office), but even with common codes there are discrepancies or gray areas. Coders must consult their manual, professional associations, and periodicals to stay up-to-date on current professional best practices.

Learn about lag days

Like medical billing, medical coding is a time-sensitive operation. Any hiccup in the coding process can cause a ripple effect, which delays billing, the claims process, and ultimately the reimbursement of the healthcare provider from the insurance company. For this reason, most coders are asked to keep their operations within a number of “lag days.” Lag days refer to time between when a procedure note is given to the coder and when the claim for that procedure is filed. Most offices keep the number of lag days between two and five, so coders must stay on top of their work in order to ensure efficiency in the operation of the health-care provider.

Review crosswalking

In certain cases, a medical billing and coding professional has to perform a code “crosswalk” between these sets of codes. Crosswalking is covered in depth in courses 11 and 12. To briefly review, a crosswalk refers to an equivalency or translation between two code sets. A medical coder may have to use a crosswalk in order to track data between two different sets of code (as in the case of ICD-10-CM and ICD-9-CM) or translate between two sets to comply with certain form requirements (as with translating CPT codes into ICD-9-CM codes).

Avoid clerical errors to shorten reimbursement time

Coders should also make sure the procedural and diagnostic codes that they are entering on a claim make sense with one another. For example, you would not want to pair the procedure code for a tonsillectomy with the diagnosis code for a broken hand. Inaccurate, contradictory, or improperly crosswalked codes are just a few of the many reasons a claim may be denied, and it is up to the coding specialist to prevent as many of these clerical errors as possible.

Understand the role of medical billers

As stated earlier, the job of the medical biller aligns closely with that of the medical coder, but there are other integral tasks that are unique to the medical biller. As you read in Course 2, the initial part of the medical billing process is the collection of data from the patient. Medical billing specialists must ensure they have all the relevant information from the patient and that this information is correct in order to proceed with a claim to the insurance company.

Once medical billers have the correct information regarding a patient’s history, contact information, and insurance policy (or policies), they then input that information into their medical claims software and begin the claims process. Upon translating the procedure notes into diagnostic and procedural codes (or upon receiving these codes from a third-party coder), the medical biller creates an insurance claim and sends this to an insurance company. Medical billers should be familiar with claim formats for each of the major payers, including Blue Cross/Blue Shield (and other private payers), Medicare, Medicaid, TRICARE, CHAMPVA, and various worker’s compensation and disability organizations.

When the claim is returned and the healthcare provider is properly reimbursed for services, medical billers must then bill the patient. This process involves following up with patients about late payments or arranging for a collections service in the case of notably delinquent bills. Medical billers are also responsible for interpreting the Explanation of Benefits (EOB) and explaining the general billing process to patients. Medical billers must be familiar with co-pays, coinsurance, and deductibles in order to bill patients correctly.

If a claim is returned to the healthcare provider as denied or rejected, the medical billing expert must determine why and correct errors if possible. If the claim was denied because of inaccurate or inappropriate coding, the medical biller must input the correct codes and resubmit the claim (or pass it back to the third-party coder who initially coded the procedure).

Medical billers must also prepare appeals to denied claims on behalf of patients or the healthcare provider. A denied claim may be due to a clerical error (as with a missed code), or it may come down to a discrepancy in the provider’s contract with a payer. Medical billers also have to help patients prove the necessity of their medical procedure. They must be prepared to research all of the elements of the appeals process. As with coding, the appeals process is time-sensitive, so medical billers handling claim appeals must work quickly and efficiently to ensure their appeal is filed in a timely manner.

See What Tools You Will Use as a Biller and Coder

Many professionals in the field rely heavily on billing and coding software. This software is especially important if you are planning on working from home. Software like Medisoft or MediTouch allow coders to look up specific codes for accuracy and create claims quickly. There are dozens of billing and coding software programs at various price points, and you will have to assess what your individual needs and preferences are when it comes to the coding software you use.

While medical billing and coding software is becoming an industry standard, some smaller practices still use paper hard copies for their coding and billing services. Paper is less efficient than electronic records, and can create problems such as duplicate data (in the case of there accidentally being two separate files for one patient), not to mention the massive amount of physical space needed for storage of paper claims. Coding and billing via hard copy also makes it difficult for different parties (like other insurance companies or healthcare providers) to access important health records. Still, despite the clear advantages of electronic health records for the purposes of billing and coding, professional billers and coders should familiarize themselves with hard copy billing and coding forms. Medical billers also have to refer to hard copies of a patient’s medical records and EOBs throughout the day when creating a claim.

Find Out What Regulations You Have to Follow

While there are no laws that apply exclusively to medical billing and coding, billers and coders must operate within the laws and regulations that govern the whole of the healthcare industry. Because the information they handle includes confidential patient medical histories, they must follow guidelines laid out in the Health Insurance Portability and Accountability Act (HIPAA), and the Correct Coding Initiative, which is a project of the Centers for Medicare and Medicaid (CMS).

Title II of HIPAA, also known as the Administrative Simplification Statute, ensures that the confidentiality of patients will be secure when their information is transmitted electronically. This applies to all entities that handle health information electronically, including health plans, healthcare providers, and healthcare clearinghouses. These rules also apply to any off-site or third-party entity (such as a freelance biller or coder) that handles sensitive healthcare information. The HIPAA Administrative Simplification Statute states, effectively, that all parties capable of accessing or transmitting sensitive health information have a set of rules in place that a) protect patient health and b) identify which employees or persons will have access to a particular level of private information. Privacy rules may vary from one practice to another, and HIPAA mandates internal audits as a primary method of ensuring adherence to the law. Audits may mean a routine review of protocol and procedure for the medical coder and biller.

Note that this part of HIPAA applies only to electronic transactions, including claims and encounter information (such as ICD-10-CM codes) and inquiries into claim status. Healthcare providers, coders and billers, clearinghouses, and insurance companies are not required to submit this information electronically, but if they do, they must follow HIPAA guidelines.

The Correct Coding Initiative provides detailed guidelines for professional coders and billers. Updated annually by CMS, the initiative ensures that the codes used for various medical transactions are uniform around the country. You are already familiar with certain initiative regulations: The initiative mandates that Current Procedural Terminology (CPT) be used to code medical procedures, and that ICD-10 be adopted by October 1, 2014 for all diagnostic reports. The Correct Coding Initiative also regulates which codes will be used in pharmacy and dental transactions. The medical biller and coder should be aware of these regulations and be able to research them whenever the need arises.

Start Your Own Business

The medical billing and coding field is expected to grow steadily in the next few decades. As health informatics change and the healthcare industry continues to expand, coders and billers will be in demand to cope with the increased burden of processing information that changes hands during a medical procedure. Third parties sometimes perform billing and coding operations, and there are opportunities for entrepreneurs to build their own billing and coding business.

One of the interesting benefits of starting a billing and coding profession is the ability to work from home. Because the job requires mostly clerical work that can be done on a computer, a medical biller and/or coder does not need to work from a medical office or even interact with patients directly. However, starting your own coding and billing business will not be easy. Even if you are working from home, you’ll have to stay in frequent contact with your clients, health insurance companies, and clearinghouses. Explore the following tips to running your own successful billing and coding business:

1) Get certified

Certification is not formally required for medical billers and coders, but if you’re starting your own business, you’ll want to have a certification from a school or training program that’s recognized by either the American Health Information Management Association (AHIMA) or the American Association of Professional Coders (AAPC). This certification will assures prospective clients that you have achieved a certain level of expertise and dependability.

2) Get experience

Before you start your own billing and coding service, you’ll want to get some experience working at a healthcare provider’s office. While it might not make sense to start your own at-home business working for someone else, you’ll have a very hard time finding any clients willing to entrust the sensitive health information of their patients to an unknown third party. Working for an established provider grants you a reference, proof of your legitimacy, and possibly even future clients.

3) Know the law

As you pursue certification, you’ll undoubtedly learn the regulations and laws that govern the day-to-day tasks of a medical biller and coder. However, don’t forget about local, state, and federal laws, as well. If you’re going to run your own billing and coding service, you’ll need to apply for a business license. You may also need to apply for special licenses within your state. Some medical billing agencies, for example, must be registered as collections agencies. You may also need to get a federal tax ID number for your small business. It’s worth the time and money to consult a professional accountant or financial adviser when it comes to setting up these licenses.

4) Get the tools

Like any start-up business, a medical billing and coding business will require some initial investment. Fortunately, unlike the capital needed for a lot of other small business, this investment is relatively low. You’ll have to invest in coding, billing, and accounting software, such as Quickbooks. You should invest in high-quality software (which may cost as much as $1,500), and avoid any program that seems too good to be true. You’ll also have to budget for expenses such as a computer and monitor, a fax machine/copier/scanner, separate phone line, reference books, clearinghouse fees, and more. To save money, explore all your options when searching for reference books. For instance, reference books can cost around $450, but there are online reference services that are available for around $30 per month. Also, set aside a space in your home for an office, and furnish it accordingly. Lastly, add the cost of training and certification into your start-up budget. All in all, be prepared to spend between $4,000 and $6,000 to start your coding and billing business.

5) Actively pursue networking opportunities

Once you’ve got your certification and business license and your home office is set up, it’s time to reach out to clients. If you worked with a provider before starting your own business, that provider may have work for you, or may be able to suggest other offices in need of coding and billing services. Note that smaller practices may have less on-site administrative help and could be interested in outsourcing coding and billing tasks. You may also want to choose a medical specialty, like cardiology or radiology. If you become proficient in a certain area of coding and billing, it’s easy to reach out to different practices that focus on the same thing. Set up a website for your business and keep it updated regularly.

You should also network the old-fashioned way, by attending conferences and joining professional associations. Professional associations like the AAPC provide valuable resources and opportunities to learn from other individuals in your field.

6) Get paid

When you’re about to begin work with a client, you’ll have to work out how you’ll be paid. Third-party coders can be paid by the hour, by the claim, or by a percentage of that client’s monthly revenue. The payment arrangement will depend on a number of things, such as the size of the practice and the frequency of patient visits. A general practitioner, for example, can have more than 40 office visits a day and charge a small amount, while a radiologist may have only a few visits but charge a significantly higher amount. Whichever payment rate you decide on, be sure to get that rate in a written contract.

A Guide to the Use of CPT MODIFIERS

In order to describe the myriad number of different medical services, procedures, and factors accurately, CPT codes are divided into three Categories. Category I CPT codes describe medical, surgical, and diagnostic procedures (for instance, a routine checkup of low complexity is CPT code 99213). Category II CPT codes provide supplemental information to Category I CPT codes. The example used in Course 12 is the code for low-density lipoprotein cholesterol (CPT I code 80061) with a result of less than 100 mg of cholesterol per deciliter (CPT II code 3048F). This test and its result would be coded as 80061-3048F.

Category II CPT codes supply information that streamlines administrative work and tracks the performance of certain tests or procedures. These Category II codes, however, do not always provide important information about the specifics of a procedure, like on which side of the body a surgery took place, or whether a surgery was discontinued due to concern for patient safety.

See Examples of CPT Modifiers

In order to communicate this extremely detailed information in an efficient, standardized way, the AMA created CPT modifiers. CPT modifiers are two-character suffixes that healthcare providers or coders attach to a CPT code to give additional information about the procedure documented. CPT modifiers are always two characters in length. They may consist of two numbers from 21 to 99, two letters, or a mix (alphanumeric). These modifiers are appended to the initial CPT code by a hyphen.

Some examples of common CPT modifiers include:

• -53 (discontinued procedure)
• -59 (distinct procedural service)
• -79 (unrelated procedure or service performed by the same physician during the postoperative procedure).

Some common letter-based modifiers include:

• -LT (denotes a procedure on the left side of the body)
• -RT (denotes the right side of the body),
• -GC (identifies that a service has been performed by residents or students under the guidance of a teaching physician).

If you had to code a partial mastectomy of the left breast, you would use the CPT code 19302 for the procedure, with the modifier –LT to describe on which side of the body the procedure took place. Our code would read 19302-LT. If, however, the procedure had to be stopped because of a concern for the well-being of the patient, you would add another modifier: -53. The new code would read 19302-LT-53. Note that this is a simplified example, and that a procedure as complex as a mastectomy often has numerous additional codes).

Certain CPT modifiers are only used with a particular type of procedure or service. For instance, the modifier –LT used above is only valid when describing a procedure on an appendage or organ paired in the body, such as the lung, kidney, leg, or breast. The modifiers, -21, -24, -25, and -27 are only used for evaluation and management. Also, note that unlike CPT codes and ICD codes, CPT modifiers are not necessarily grouped into related procedures.

Functional vs. informational modifiers

There are a number of additional rules that govern the use of CPT modifiers. Coders must constantly look out for certain restrictions, formats, and guidelines, as a miscoded CPT modifier can result in a denied claim. Medical coders typically only use two CPT modifiers. While there is room for up to four modifiers on the CMS 1500 and UB-04 claim forms, the Center for Medicare and Medicaid Services (CMS) or other payers may not recognize modifiers after the first two. For this reason, coders should list first the modifiers that will affect reimbursement. These are often called functional or pricing modifiers, while modifiers that provide information about the procedure are known as informational. There are certain CPT modifiers, such as -22 (for unusual procedural services) and -52 (for reduced services), that affect reimbursement if documentation supports the use of this modifier.

Take, for example, the partial mastectomy of the left breast (code 19302-LT-53). If you were to swap out the -53 (discontinued procedure) with the functional modifier -52 (for reduced services), you would then code the whole procedure 19302-52-LT. Note that the functional modifier (-52) now comes before the informational modifier (-LT). If the informational modifier is listed first in a claim, an insurance company will deny that claim and return it to the healthcare provider.

Certain modifiers also have guidelines specific to them. The modifier -51, for multiple procedures, is one of the more commonly used CPT modifiers. In the instance of multiple procedures provided by the same specialist or healthcare provider, a coder would list the initial procedure’s CPT code, then append the modifier -51 to the end of the code for the additional procedure or procedures. Certain procedures, however, are listed in the CPT book as “-51 exempt,” and coders must be aware of this distinction.

Note that some modifiers can be used in conjunction with each other (like -23, unusual anesthesia, and -47, for anesthesia by surgeon). Others contradict one another and cannot be included in the same code For example, the modifier –LT (procedure on the left of two paired appendages or organs) cannot be coded with the modifier -50, which describes a bilateral procedure.

ICD-9 to ICD-10 Medical Coding Crosswalk

The United States healthcare system will discontinue its use of ICD-9-CM diagnostic codes and upgrade its entire system to the next revision of the code: ICD-10-CM. Because ICD codes are integral to the medical billing process, the changes are taking place at every level of the patient-provider-payer relationship. As the person who interacts with diagnostic codes on a daily basis, the medical coder must be prepared for this transition. A medical coder must be fluent in both ICD-9-CM and ICD-10-CM in order to make the switch as seamlessly as possible.

This change was originally planned for October 1st, 2014 , however, the U.S Senate  introduced a bill on March, 26th, 2014 that will delay the change of ICD-9-CM to ICD-10-CM until October 1st, 2015.

A process called crosswalking is used to translate from one code to another. Crosswalking means mapping or translating a code from one set to another. Use the AAPC tool below to crosswalk between the different coding systems.

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Learn Why the Change Will Happen

In order to understand this important shift in health informatics, it’s important to first look at why the change is occurring. ICD-9-CM is being phased out because it is outdated (published in 1978) and not flexible enough to deal with changes and expansions to medical procedures and diagnoses. To put it another way, ICD-9-CM is out of room. As new methods, diseases, and diagnoses are discovered, ICD-9-CM has been unable to find space in its code to accurately report these advances in medicine. ICD-9-CM caps out at around 13,000 codes, while ICD-10-CM has roughly 68,000.

Explore How the Change Will Happen

Being able to perform translations between ICD-9-CM and ICD-10-CM codes is a vital skill for a professional coder. One way in which translation is useful is that you can crosswalk codes back to ICD-9-CM if you are tracking or analyzing data. For example, if you are creating a report on the 2014 calendar year (which, again, will see the use of both ICD-9-CM and ICD-10-CM codes), it may be easier to crosswalk ICD-10-CM codes back to ICD-9-CM to create a standard set of data. Crosswalking will also help you update your records and programs.

There are, however, a number of difficulties in this process. Because ICD-10-CM expands so significantly on the body of codes in ICD-9-CM, there are a number of discrepancies and inaccurate or incomplete translations between the two code sets. It’s the medical coder’s job to watch out for these discrepancies and become familiar with crosswalking procedure as the deadline to switch from ICD-9-CM to ICD-10-CM approaches. Note that it is impossible in most cases to perform a 100 percent accurate translation from one code set to the other, as ICD-10-CM is significantly different from ICD-9-CM in terms of the format, concept, and structure.

One resource that will help you learn to crosswalk between the two code sets is the National Center for Health Statistics’ General Equivalence Mappings, or GEMs. These GEMs find and list equivalencies between the code sets, and they are considered the authoritative source for mapping between both sets. The GEMs allow you to map forward and backward between ICD-9-CM and ICD-10-CM. Coders should be familiar with both processes.

Understanding Different Code Matches

There are different types of matches that occur between the ICD-9-CM and ICD-10-CM code sets. The AMA identifies four types of matches between the two code sets, and an additional type that is reserved for “no match.”

One-to-one exact matches

In one-to-one matches, a coder is able to identify an exact match between the two code sets. These are relatively rare; only 5% of codes translate exactly from ICD-10-CM to ICD-9-CM, and just over 24 percent map directly in the opposite direction. One example is the ICD-9-CM code 416.0 (primary pulmonary hypertension) and the ICD-10-CM code I270 (primary pulmonary hypertension).

One-to-one approximate matches with one choice

A significantly more common occurrence in ICD code crosswalking is a one-to-one approximate match. In fact, 82.6 percent of ICD-10-CM codes can be backward-mapped this way, while 49.1 percent of ICD-9-CM codes can be forward-mapped to a similar degree of accuracy. It should be noted that this is not a direct translation, but more of a “close enough” approximation. For example, the ICD-9-CM code 422.91 (idiopathic myocarditis) is an approximate match for ICD-10-CM code I401 (isolated myocarditis).

One-to-one approximate matches with multiple choices

Exact and approximate matches with one choice make up the majority of ICD code crosswalking, but there are still a large number of codes that do not translate with the same level of accuracy. Approximate matches with multiple choices put much more responsibility on the coders, as they must pick the best fit from a number of similar choices. In certain cases, different diagnoses may fall under one code in the other set. For example, ICD-10-CM codes C220 (liver cell carcinoma) and C22 (hepatoblastoma) both correspond to ICD-9-CM code 155.0 (malignant neoplasm of the liver, primary). Each code set has instances of different diagnoses corresponding to only one code in the other. Coders must pay attention to these areas, as a miscoded diagnosis could affect the status of a claim.

One-to-many matches

By far the most difficult instance of crosswalking, one-to-many matches involve one code in a code set corresponding to several codes in the other. For instance, the ICD-9-CM code 80010 (closed fracture of vault of skull with cerebral laceration and confusion, state of consciousness unspecified) corresponds to two different codes in ICD-10-CM: S02.0xxA (fracture of the vault of the skull, initial encounter for closed fracture) and S06.339A (contusion and laceration of the cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter). Essentially, the diagnosis code in one set must be created out of multiple codes in another set. The groups of codes that translate to a single code in another set are called “clusters.” Clusters are always between two and four codes in size. Some single codes may correspond to multiple clusters. All codes in a cluster need to be listed in order to fully represent its corresponding translation. This process of translating one-to-many matches requires diligence and constant review, as a code missing from a cluster creates fundamental inaccuracies in your report.

ICD-9-CM and ICD-10-CM Codes

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is a system used by physicians and other healthcare providers to classify and code all diagnoses, symptoms and procedures recorded in conjunction with hospital care in the United States.


The International Classification of Diseases (ICD) code is one of the most essential pieces of the medical billing and coding process. Created by the World Health Organization (WHO) as a way of standardizing healthcare classification, ICD codes are diagnostic codes that represent all aspects of a medical diagnosis, including symptoms, social circumstances, cause of injury or disease, and more.

Exploring the ICD-9 and ICD-10 with Easy Lookup Tools
On this page are two tools for investigating ICD-9-CM and ICD-10-CM codes. They are a good place to get started with your education in medical billing and coding.

ICD-9-CM Tool

To use the ICD-9-CM tool, simply type the name of a disease or injury in the search field. The search engine should then give you the corresponding ICD-9-CM code. You can look up that code in the ICD-9-CM index, available through the CDC. You will have to download a copy and open it as an RTF file.

ICD-10-CM Tool

Use the ICD-10 -CM Tool to search by the name of the disease or injury, or by the code itself. You can then take your search results and use them to find more information on the World Health Organization’s version of ICD-10-CM. Click on the chapter title (like “diseases of the respiratory system”) in the drop-down menu on the left to get a list of code blocks that chapter contains. You can also click the arrow button to the left of the chapter title to navigate the drop-down menu from the sidebar.

Background on the ICD

ICD-9—the ninth revision of the International Classification of Diseases—was published in 1978 by the WHO and adapted for use in America by the NCHS. ICD codes were originally intended to be used for epidemiological purposes, but in the United States these codes are used by healthcare providers and insurance companies for billing and reimbursement.

In America, “CM” stands for “Clinical Modification,” which was instituted in the United States by the National Center for Health Statistics (NCHS) to provide additional information related to diagnosis and procedural codes. The CM allows for a much wider spectrum of specific information. ICD-9-CM is updated annually on October 1st in order to reflect new diagnoses, practices, and procedures in the healthcare industry.

How the ICD-9-CM Works

ICD codes create a standard vocabulary for identifying causes of illness, injury, and death around the world.

Physical copies of the ICD-9-CM codes are divided into volumes. Volume 1 contains a tabular list of codes (codes listed by number with the diagnosis following the number) and Volume 2 contains an alphabetical list of symptoms and diagnoses. The third volume for each of these contains procedure codes, which are only used by hospitals to report surgeries performed in their facility. Healthcare providers and insurance companies only use the first two volumes. For the purposes of this course, you will be looking up ICD codes entirely online, but it is still helpful to understand the organization of the ICD manuals.

The 5-digit numeric ICD-9-CM codes are organized from 000 to 999 according to the type of disease or injury they describe. For instance, codes in the 320-359 range represent diseases of the nervous system, such as encephalitis or meningitis. Codes 800-999 correspond to injury and poisoning, like dislocation (codes 830-839) or poisoning by drugs, medications, or other biological substances (codes 960-979).

Those first three digits in an ICD-9-CM code describe the general type of injury or disease, and are called the “category.” The category can be followed by a decimal point and up to two other digits, which provide more specific information about the type, location, and severity of the disease or injury. These last two digits are called the subcategory, and allow coders to increase the level of specificity of their report on a disease or injury.

Example:

The code 722.52 corresponds to degenerative disc disease of the lumbar, where:

• The 3-digit code, or category, “722” corresponds to “intervertebral disc disorders” in the list of diseases and injuries
  • The two-digit sub-subcategories refers to degenerative disc disease, lumbar

Generally speaking, the more digits in a code, the more specific the type, cause, and/or area of injury or disease.

There are also two sets of alphanumeric codes in ICD-9-CM. E-codes describe external causes of injury, while V-codes describe factors that influence health status and/or describe interactions with health services. An example of an e-code would be E905.2, which describes a scorpion sting causing poisoning and toxic reactions. An example of a V-code is V30.00, which describes a single live infant (V30) born in a hospital (V30.0) without mention of caesarean section (V30.00). Like the numeric codes in ICD-9-CM, each of these codes has varying degrees of specificity based on the incident.

Preparing for the Change to ICD-10

The ICD-9-CM will be replaced by the updated ICD-10 in late 2014. In order to comply with this change, healthcare providers, insurance companies, and clearinghouses must all be prepared to fully adopt ICD-10-CM by October 1, 2014. All claims filed with ICD-9-CM after that date will be rejected as non-compliant. Procedures arranged or completed before that date may still be filed with ICD-9-CM.

This switch is happening for a variety of reasons. For one, the ICD-9-CM is out of room. ICD-9-CM is set up so every category can only have 10 subcategories. As it currently stands, the ICD-9-CM can only classify around 13,600 diagnoses, compared to ICD-10-CM’s estimate of 69,000. As diagnoses continue to expand, the system can no longer support the breadth of medical study. The ICD-10 is also better suited for modern technological advances in the field, allowing for more optimized analysis of disease patterns and treatment outcomes.

There are similarities between the two code sets. The conventions and guidelines for assignment codes are largely the same, as is the organization of both sets. For instance, the first chapter, or category cluster, in both ICD-9-CM and ICD-10 is “Certain infectious and parasitic diseases,” so any professional qualified to manage ICD-9-CM should not have a problem with ICD-10. However, there are also key differences between the ICD-9-CM and ICD-10 systems, requiring a conversion on the part of the medical coder.

The composition of codes in the ICD-9-CM is primarily numeric, with limited alphanumeric additions, as discussed above. Valid ICD-9-CM codes are three, four, or five digits. In ICD-10-CM, all codes are alphanumeric and may be anywhere from three to seven digits, depending on the need for specificity. For instance, in ICD-9-CM, the cluster for “Certain infectious and parasitic diseases” is 001-139. In ICD-10 that same cluster would be labeled A00-B99.

Here is a broader example of the tabular breakdowns in ICD-9-CM and ICD-10:

ICD-9-CM

• Certain infectious and parasitic diseases (001-139)
  • Intestinal infectious diseases (001-009)
    • Cholera (001)
      • Cholera due to vibrio cholerae (001.0)
      • Cholera due to vibrio cholerae eltor (001.1)
      • Unspecified (001.9)

ICD-10

• Certain infectious and parasitic diseases (A00-B99)
  • Bacterial infections, other intestinal infectious diseases, and STDs (A00-A79)
    • Intestinal infectious diseases (A00-A09)
      • Cholera (A00)
        • Cholera due to vibrio cholerae (A00.0)
        • Cholera due to vibrio cholerae eltor (A00.1)
        • Unspecified (A00.9)

As you can see, the two code sets are largely similar, but with key differences. The alphanumeric numbering system of ICD-10 follows the same tabular tree as the numeric system in ICD-9-CM, adding a new subcategory within the A00-A79 cluster. As medical coders prepare for the shift, plenty of resources will be made available to translate ICD-9-CM into ICD-10.

Because ICD-10 and ICD-10-CM have a significantly larger set of codes than ICD-9 and ICD-9-CM, direct translation between the two code sets is impossible. The translation of ICD-9-CM codes into ICD-10-CM codes using a “crosswalk” program will be discussed in Course 11.

Watch for Coding Notes

In many cases, codes will have notes attached to them that prevent redundancies or inaccurate coding. These notes help medical coders accurately translate the diagnosis into code, and may include instructions like:

• “Code first,” in which case the coder must list an underlying condition or prior procedure
• “Includes,” which tells the coder which symptoms or afflictions the code contains
• “Excludes” or “excludes1,” which are especially important. Unique to ICD-9-CM, the “excludes” note instructs the coder that there is another, more appropriate code for a certain diagnosis. “Excludes1” indicates that the term listed under the “excludes1” field cannot occur simultaneously with the term listed above it. For example, systemic inflammatory response syndrome (SIRS) is coded as R65.1, but excludes severe sepsis (R65.2).

Those these notes can be complicated, they are essential for coding accurately. Even the smallest mistake can cause a medical claim to be denied, creating more work for the office and possibly delaying vital payments from the insurance company to a patient.

The Medical Coding Process

Medical coding is usage of standardized codes to diagnose the services rendered to a policyholder. Every possible injury and diagnosis is assigned a universal code that is readily understood by both healthcare providers and insurance companies so these parties are operating under the same umbrella of information. This process has become particularly useful, in terms of efficiency, ever since the claims process moved over to a largely digitized format.

Because clinical documentation practices vary, the process of abstracting code-able information about the patient involves some detective work. Coders must sift out the crucial information regarding diagnosis and treatment from the documentation. For example, a coder might receive a clinical file that looks like this:

• Date of Procedure: 6/13/20xx
• Patient Name: Jaswinder Patel
• DOB: 11/28/19xx
• HPI: Mr. Patel is a 27-year-old male who states he was doing light chores around the house when he fell off a ladder and felt sharp pain in his left hand. Upon receiving advice from his neighbor, he sought medical treatment.
• Past Medical: History of sinusitis
• Diagnosis: Multiple fractures of hand
• Procedure: Splint

Workers on the administrative side of healthcare and insurance may be prone to misunderstanding the technical terms in this document. Therefore, after the diagnosis and procedures are complete, this medical statement is given to the medical coder, who looks at this report and sifts out the most crucial information that needs to be reported to the insurance company: the diagnosis and procedure, or treatment, prescribed by Mr. Patel’s physician. Coders convert the diagnosis and treatments into a code set, “translating” the physician’s jargon into the universal medical language understood by all healthcare professionals.

The medical coder then hands the converted data to the medical biller, who sends the claim to the policyholder’s insurance company. Often, the medical coder and the medical biller are the same person.

Coding Diseases: Navigating the ICD

The standard accepted code set for medical diagnosis is called the International Classification of Diseases, or ICD. The ICD was created by the World Health Organization (WHO). Since the medical field, particularly in the realm of diagnosis and treatment, is constantly changing when new treatments evolve, many updates of the ICD have been issued since its initial conception. Despite being more than 30 years old, the Ninth Revision of the International Classification of Diseases (ICD-9) is still the primary code set in use in the United States. However, ICD-10 is due to be implemented in the United States on October 1, 2014 and students interested in this field should be prepared for the change, which is discussed further in Course 10.

Since there are thousands of different diagnoses needing to be represented in code, down to extremely specific diagnoses, the coding system needs to be extensive, but easy to navigate. Medical coders navigate these codes using conventions, or guidelines for selecting and sequences ICD-9-CM codes. They are generally set up in a tabular list to make navigating easier.

Reading the ICD codes

An ICD-9-CM code is broken down into categories and subcategories, and can contain as many as five digits. To take Mr. Patel’s injury, for example, coders use the ICD-9-CM code for “multiple fractures of hand bones” is 817, or 817.0. The three digits before the decimal denote the category. It falls within categories 810-819, or “Fracture of the upper limb.” The categories 810-819 themselves fall within the larger categories 800-999, or “Injury and poisoning.”

The digit after the decimal is called the subcategory. In the case of this diagnosis, 817 (817.0) is the default, since it has no subcategory and represents “multiple closed fractures of the hand bones.” If the fractures were open, the ICD-9-CM code would be 817.1, or “multiple open fractures of the hand bone.” The digit “1” marks the subcategory of open fractures.

To review, if a medical coder received a statement listing “multiple open fractures of the hand bone,” or alternative language that describes the same diagnosis, the coder may navigate the ICD-9-CM codes through the following breakdown:

• Injury and poisoning (800-999)
  • Fractures (800-829)
    • Fractures of the upper limb (810-819)
      • Multiple fractures of the hand bones (817)
        • Multiple open fractures of the hand bones (817.1)

The categories and subcategories break down in a logical manner. The medical coder will always have a comprehensive reference guide to break down the ICD-9-CM using this tabular system.

Coding Treatments: Using the CPT or HPCPS

In addition to translating the diagnosis to the appropriate ICD code, medical coders convert the treatment to a CPT code or HCPCS code. The differences are explored below.

Exploring the CPT

Despite how extensive it is, the ICD is just one portion of medical coding, as it covers only diagnoses. There is an entirely separate code set for medical treatments. This code set is called Current Procedural Terminology (CPT), and is copyrighted and maintained by the American Medical Association’s CPT Editorial Panel.

CPT codes refer to the wide range of all medical procedures, including every task and service performed by a medical practitioner. These codes are broken down into three categories. The majority of CPT codes exist in Category I. Category II is reserved for optional performance measurement, and Category III denotes emerging technologies.

Like the ICD system, CPT codes are broken down into categories. Unlike ICD codes, the CPT codes do not exist in detailed tabular format, and are broader in their organization.

Category I is broken down into six main sections:

• Codes for Evaluation and Management: 99201-99499
• Codes for Anesthesia: 00100-01999; 99100-99150
• Codes for Surgery: 10021-69990
• Codes for Radiology: 70010-79999
• Codes for Pathology & Laboratory: 80047-89398
• Codes for Medicine: 90281-99199; 99500-99607

Individual sections are then broken down further. For example:

• Codes for Evaluation and Management: 99201-99499
  • Office/other outpatient services 99201-9215
  • Hospital observation services 99217-99220
  • Hospital inpatient services 99221-99239
    Consultations 99241-99255
  • Emergency department services 99281-99288
  • Critical care services 99291-99292

Because the CPT is copyrighted and run by the American Medical Association, a comprehensive list of codes is generally not made available to the public.

Using the HCPCS

Not all insurance providers accept the CPT. Medicare and Medicaid (both of which will be discussed below) use the Healthcare Common Procedure Coding System (HCPCS). This coding system is comprised of two levels.

Level one consists of the CPT codes and is identical in its implementation. Level two is a coding system that is used to identity medical products and services not included in CPT codes, such as ambulance services, prosthetics, and durable medical equipment. These products and services are usually used outside of the medical practitioner’s office, and Medicare/Medicaid often cover these services where other insurance providers may not.