Overview of Current Procedural Terminology (CPT) Coding System
The CPT coding system describes medical, surgical, and diagnostic services performed by physicians and other health care professionals. The coding system, developed and maintained by the American Medical Association (AMA), offers health care providers “a uniform process for coding medical services that streamlines reporting and increases accuracy and efficiency.” CPT codes are not the same as ICD-10 codes. While CPT codes are similar to ICD-10 codes, CPT codes identify services rendered, whereas ICD-10 codes represent patient diagnoses. (For additional information on ICD-10 codes, please refer to the ICD-10: Understanding the Basics document).
The Centers for Medicare and Medicaid Services (CMS) uses the CPT coding system to establish reimbursement to Medicare providers. Each CPT code has a relative value unit (RVU) assigned to it, a rate that is reviewed every few years. RVUs are the standard measurement in analysis of reimbursement and payer contracts, physician compensation and productivity, and practice staffing and operating costs. Medicare fee schedules are based on RVUs. The majority of commercial insurers base their reimbursement levels on either the Medicare fee schedule or RVUs. It is important for athletic trainers (ATs) to understand how insurers reimburse health care providers for services rendered. Insurers generally pay health care professionals for services based on submission of a claim using one or more specific CPT codes. The calculation of a code’s RVU is simpler than it seems. Below is the formula used to calculate payments for furnished services:
- (Physician Work RVU [Relative time and intensity to provide a service] x Geographical Practice Cost Indices (GPCI) [Accounts for geographic differences in the cost of practice across the country]) +
- (Practice Expense RVU [Costs of maintaining a practice, including rent, equipment, supplies, and non-physician staff costs] x Practice Expensive GPCI) +
- (Malpractice RVU [Represents cost of professional liability expenses] x Malpractice GCPI) = Total RVU.
- Then, Total RVU x Conversion Factor = Allowable reimbursement.
Commonly Used CPT Codes and Modifiers
The following list of CPT codes and commonly used modifiers is in no way exhaustive and represents the codes and modifiers most often used in clinical practice by ATs. For complete descriptions and listing of all current CPT codes, and their modifiers, please refer to Centers for Medicare & Medicaid Services page or the most recent official American Medical Association (AMA) CPT Code Book with rules and guidelines from the AMA’s CPT Editorial Panel, as well as other resources commonly found on the internet.
"Throughout the CPT code set, the use of terms such as “physician,” “qualified health care professional,” or “individual” is not intended to indicate that other entities many not report the service. In selected instances, specific instructions may define a service as limited to professionals or limited to other entities (e.g., hospital or home health agency)." (CPT Code Book, Page xii)
- This statement means that CPT codes are not "profession specific." Any qualified health care professional can utilize any code as long as the code description fits the procedure or service the qualified health care professional is providing.
- Documentation must be appropriate to support the CPT code that is utilized.
- If not properly documented, the code will be denied.
New and revised Physical Medicine and Rehabilitation Codes (Effective January 1, 2018)
- 97127 (HCPCS Code G0515)
For CY 2018, the CPT Editorial Panel revised the Physical Medicine and Rehabilitation codes for a physician or other qualified health care professional (ie, therapist) required to have direct (one-on-one) patient contact to report orthotic and prosthetic management and training services by differentiating between initial and subsequent encounters. The descriptors for CPT codes 97760 and 97761 have been amended to include the term “initial encounter” and CPT code 97763 has been created in place of CPT code 97762 to describe all subsequent encounters for orthotics and/or prosthetics management and training services. The new long descriptors for CPT codes 97760 and 97761 – now intended only to be reported for the initial encounter with the patient − are listed below:
- 97760: Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes)
- 97761: Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes)
CMS will add CPT code 97763 to the therapy code list and CPT code 97762 will be deleted.Just as its predecessor code was, CPT code 97763 is designated as “always therapy” and must always be reported with the appropriate therapy modifier, GP.
The panel also created, for CY 2018, CPT code 97127 to replace CPT code 97532. CMS will recognize HCPCS code G0515, instead of CPT code 97127, and add HCPCS code G0515 to the therapy code list. CPT code 97127 will be assigned a MPFS payment status indicator of “I” to indicate that it is “invalid” for Medicare purposes and that another code is used for reporting and payment for these services.HCPCS code G0515 is designated as a “sometimes therapy” code, which means that an appropriate therapy modifier, GP, is always required when this service is furnished by therapists; and, when it’s furnished by or incident to physicians and certain Nonphysician Practitioners (NPPs), when the services are integral to a PT plan of care.
The therapy code list is updated with one new “always therapy” code and one new “sometimes therapy “code, using their HCPCS/CPT long descriptors, as follows:
CPT code 97763 – This “always therapy” code replaces/deletes CPT code 97762.
- CPT code 97763 Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes
HCPCS code G0515 – This “sometimes therapy” code replaces/deletes CPT code 97532.
- HCPCS code G0515: Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes
Athletic training evaluation codes (effective january 1, 2017)
- 97169 Athletic Training evaluation, low complexity
- 97170 Athletic Training evaluation, moderate complexity
- 97171 Athletic Training evaluation, high complexity
- 97172 Athletic Training re-evaluation
The level of the athletic training evaluation performed is dependent on clinical decision-making and the nature of the patient’s condition (severity).
Athletic training evaluations include a patient history and an examination with the development of the plan of care, conducted by the physician or other qualified health care professional.
Coordination, consultation, and collaboration of care with physicians, other qualified health care professionals, or agencies is provided consistent with the nature of the problem(s) and the needs of the patient, family, and/or other caregivers.
At a minimum, each of the following components must be documented in order to report the selected level of athletic training evaluation. Athletic training evaluations include the following components:
- History and physical activity profile
- Clinical decision making
- Development of plan of care
PHYSICAL MEDICINE & REHABILITATION CODES
The application of a modality that does not require direct (one-on-one) patient contact.
- 97018 Paraffin bath therapy
- 97022 Whirlpool therapy
- 97024 Diathermy eg microwave
- 97028 Ultraviolet therapy
The application of a modality that requires (one-on-one) patient contact.
- 97032 Electrical stimulation, manual, each 15 minutes
- 97034 Contrast bath therapy, each 15 minutes
- 97035 Ultrasound therapy, each 15 minutes
- 97036 Hydrotherapy, each 15 minutes
Physician or other qualified health care professional (ie, therapist) required to have direct (one-on-one) patient contact (in addition to the new codes listed above).
- 97110 Therapeutic exercises, each 15 minutes
- 97112 Neuromuscular reeducation, each 15 minutes
- 97116 Gait training therapy, each 15 minutes
- 97140 Manual therapy 1/> regions, each 15 minutes
- 97530 Therapeutic activities, each 15 minutes
- 97535 Self-care management training, each 15 minutes
- 97537 Community/work reintegration, each 15 minutes
- 97542 Wheelchair management training, each 15 minutes
- 97545 Work hardening/conditioning; initial 2 hours
- 97546 Work hardening; each additional hour
- 97750 Physical performance test or measurement, with written report, each 15 minutes
- 96119 Neuropsychological testing (eg Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Scoring Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face
- 96120 Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report
EVALUATION & MANAGEMENT CODE
- 99211 Office/outpatient visit, est
APPLICATION OF CASTS AND STRAPPING
- 29240 Strapping; shoulder
- 29260 Strapping; elbow or wrist
- 29280 Strapping; hand or finger
- 29520 Strapping; hip
- 29530 Strapping; knee
- 29540 Strapping; ankle and/or foot
- 29550 Strapping; toes
- 29580 Unna boot
- 29581 Application of multi-layer compression system; leg (below knee) including ankle & foot
- 29582 Compression system; thigh and leg, including ankle and foot, when performed
- 29583 Compression system; upper arm and forearm
- 29584 Compression system; upper arm, forearm, hand and fingers
Health care common procedure coding system (HCPCS) LEVEL II CODES
The HCPCS coding system is divided into two levels. Level I of the HCPCS is comprised of CPT codes. Level II of the HCPCS is a standardized coding system that is used primarily to identify products, suppliers, and services not included in the CPT code set jurisdiction. For more information on the HCPCS coding system, please refer to Centers for Medicare & Medicaid Services page.
- A6441-A6457 Bandages/dressings
- E0110-E0118 Crutches
- E0720-E0770 TENS
- E1800-E1841 Orthopedic devices
- L1500-L2999 Orthotic devices
- L3650-L4130 Orthotic devices
HCFA 1500 Claim Form
A HCFA 1500 form is the official standard form that is used by physicians as well as other providers when submitting claims or bills for reimbursement to private insurers as well as managed care plans for health services. HCFA 1500 also is used to bill Medicare and Medicaid for health services.
UB 04 Claim Form
UB 04 is a billing format adopted by the National Uniform Billing Committee (NUBC). The NUBC is a voluntary committee chaired by the American Hospital Association (AHA) with representation by national provider and payer organizations. The UB 04 is the billing format utilized by all hospitals when submitting claims or bills for reimbursement.
UB 04 Revenue Codes used by ATs in Hospitals
- 0940 Other Therapeutic Services
- 0951 Athletic Training
Modifiers can be two digit numbers, two character modifiers, or alpha-numeric indicators. Modifiers provide additional information to payers to ensure the health care provider is paid correctly for services rendered. The modifiers listed below are a sample of commonly used modifiers which should be understood by ATs. Please refer to Centers for Medicare & Medicaid Services page for additional modifiers and their explanation.
- GP- Used to tell Medicare that you are billing for services provided as part of an outpatient physical therapy plan of care
- 25- Used when performing and billing for a re-evaluation and treatment on the same day. (Medicare functional outcomes).
- KX- Used when Medicare patient has exhausted their benefits for rehab services. The clinician is "certifying that the services rendered are medically necessary". Documentation must demonstrate medical necessity.
ATs and those who perform billing services for ATs may find the following links useful
- ICD-10 Information
- ICD-10-PCS Coding System, Mappings, and Related Training Manual
- ICD-10-CM Coding System, Mappings, and Guidelines
- ICD-10-CM and ICD-10-PCS (pdf)
For more information on CPT coding issues, contact:
Director of Government Affairs
NATA Government Affairs Department