What are CPT codes? The Current Procedural Terminology (CPT) codes offer medical providers a uniform language for coding medical services and procedures, increasing accuracy and efficiency.
Why do CPT codes matter? Accurate billing is essential to ethical practice. Billing codes are used for services rendered synchronously, whether virtually or in person. For prescribers, the selected CPT code is determined by a combination of time and medical decision-making (MDM).
What is included in "Time" for prescribers? Time is defined as the total time on the date of the encounter related to the service, including both synchronous and asynchronous time. The following activities are included in "time" considerations for prescribers.
Preparing to see a client (e.g., review of tests, records)
Obtaining and/or reviewing separately obtained history
Performing a medically necessary appropriate exam and/or evaluation with the client present
Counseling and educating the client/family/caregiver
Ordering medications, tests, or procedures
Referring and communicating with other healthcare professionals (when not reported separately)
Documenting clinical information in the electronic or other health record
Independently interpreting results and communicating results to the family
Care coordination (when not reported separately)
When prescribing controlled substances, checking the state PDMP
What is medical decision-making (MDM)? Medical decision-making refers to the process by which healthcare providers, in collaboration with clients or their caregivers, evaluate various diagnostic and treatment options to address health concerns or conditions. It involves assessing medical information, including symptoms, diagnostic tests, medical history, and relevant clinical guidelines, to formulate a diagnosis and develop a treatment plan tailored to the individual's needs.
MDM has three areas that prescribers must consider when determining the appropriate CPT code:
Problem(s): Number and complexity of problems
Data: The amount and/or complexity of data reviewed and analyzed
Level of risk: Risk of complications and/or morbidity/mortality of client management
MDM requires that two out of three problem(s), the amount and/ or complexity of data, and the level of risk be at or above the required level for the code selected. Problems and risks are always present in every encounter. Sufficient data elements to meet requirements for higher-level codes are often not present.
When will I use CPT codes? You'll select a CPT code when confirming a session and submitting an invoice. This selection gives us the information we need to file the claim with insurance, bill your client, and process your payment. If you are unsure which CPT code to select, check out these scenarios for clarification.
You'll choose codes from a dropdown menu. The most common codes are at the top, but you can scroll through the complete list of options. An explainer of these codes is available here. If a code isn't on the list, it may not be in our contract, so let us know by contacting the support team.