HCPCS and ICD and CPT … Oh My!
Let’s get the acronyms out of the way first:
ICD: International Statistical Classification of Disease and Related Health Problems
CPT: Current Procedural Terminology
HCPCS: Healthcare Common Procedures Coding System
Second, why do these medical codes exist in the first place?
It’s primarily about getting reimbursement for the approximately 5 billion transactions of services and products in the healthcare universe each year. There are other reasons, though, as well, including:
- Outcome measurements
- Clinical, financial and administrative performance measurement
- The design of payment systems and claims processing
- Reporting on new medical technology
- Improving reimbursement systems
- Care and disease process management
So even if you’re not a medical billing expert, knowing a bit about this subject is valuable. So here, then, is a teeny-tiny bit.
ICD is comprised of two parts, Clinical Modification, used for diagnostic coding of diseases and medical conditions (there are about 68,000 codes for this) and Procedure Coding System, for inpatient hospital procedures (about 87,000 codes). The World Health Organization manages these and they date back to 1893.
ICD Code example:
Format: 3–7 characters long (first is alpha, second is numeric, third through seventh are alpha or numeric, anything after the third character has a decimal point)
I25.110 = “Atherosclerotic heart disease of native coronary artery with unstable angina pectoris”
CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals. The American Medical Association owns the trademark and manages CPT. It’s been around since 1979.
CPT Code example:
Format: Five characters, either numeric or alpha
22222 = “Osteotomy Procedures on the Spine”
There are three categories for CPT:
CPT I – used for reporting claims and getting paid.
CPT II – used to track additional services attached to a healthcare visit. These codes are not payable and are for statistical use.
CPT III – These are fairly new to the healthcare industry and are reported to help health facilities and government agencies track the efficacy of new, emergent medical techniques.
HCPCS codes are intended to be a uniform way of classifying similar durable medical equipment, prosthetics, and orthotics. HCPCS was created in 1978 and up until 1996 its use was voluntary. The U.S. Government Centers for Medicare and Medicaid Services (CMS) manages HCPCS.
HCPCS Code example:
Format: Five characters, the first is alpha, the remaining four are numeric.
A4351 = “Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each” (this one’s our favorite!)
HCPCS has two classifications: HCPCS Level I (which, confusingly, is the same thing as CPT I) and HCPCS Level II.
HCPCS Level II is designed to represent non-physician services like ambulance rides, wheelchairs, walkers, and other durable medical equipment. Here’s a list of the major categories of HCPCS codes:
A codes: transportation, medical and surgical supplies, miscellaneous and experimental
B codes: enteral and parenteral therapy
C codes: temporary hospital OPPS
D codes: dental-related codes
E codes: durable medical equipment
G codes: temporary procedures and professional services
H codes: behavioral health/substance abuse services
J codes: drugs administered other than oral method, chemotherapy drugs
K codes: temporary codes for durable medical equipment regional carriers
L codes: orthotic/prosthetic procedures
M codes: other medical services
P codes: pathology and laboratory
Q codes: temporary codes (limited use and guidelines specific)
R codes: diagnostic radiology services
S codes: temporary national codes (non-Medicare) codes
T codes: temporary state Medicaid agency codes
V codes: vision/hearing services
If you have gotten this far, you’re pretty much an expert on medical coding. So, congratulations!
Here are a few additional references