CPT Codes for Medical Policies

Current Procedural Terminology or CPT is a registered trademark of the American Medical Association. CPT codes describe medical, including psychiatric, procedures performed by PROVIDERS and paid by PAYERS. Medical coding professionals help ensure the codes are applied correctly during the medical billing process. Types of medical codes are

• ICD 10 - International Classification of Diseases, V10
• CPT - Current Procedural Terminology)
• HCPCS - Healthcare Common Procedure Coding System
• HCUP - Healthcare Cost and Utilization Project
• HL7 – Health Level 7 (now FHIR)

Health Plans (Health Insurance Cos, CMS/HHS for Medicare & State for Medicaid, TPAs for Self-funded plans) use Clinical Policy Bulletins (CPB) to determine medical coverage and thus reimbursements. These guidelines detail Medical Clinical Policy Bulletins (CPBs) when certain medical services are considered medically necessary, cosmetic, or experimental and unproven. They help PAYERS decide what will and will not cover. Medical guidelines are based on constantly changing medical science & practices, so Health Plans review and update policies periodically. Typically, CPBs are based on:

• A review of available studies on a particular topic
• Evidence-based consensus statements
• Expert opinions of health care professionals
• Guidelines from nationally recognized health care organizations
• Peer-reviewed, published medical journals