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Home » Health Insurance, HSA's

CPT Codes: Why you NEED to know what they are

Last updated by on 10 Comments

“What is a CPT code?”

If you haven’t already, you’ll find yourself asking that question at one point or another when you’re hit with an unexpected medical bill. Particularly so if you have switched to an HDHP from a more traditional HMO/PPO health insurance plan.

I found out what a CPT code was the hard way when my health insurer would not pay the bill. I’ll share what I’ve learned, why it’s important, and how you can look up CPT codes on your own – with the goal of saving you significant money on medical expenses.

What are CPT Codes?

cpt codeCPT stands for “Current Procedural Terminology”. Every medical, diagnostic, or surgical procedure or service has an associated 5-digit CPT code assigned to it.

CPT codes are created, trademarked, and published by the American Medical Association (AMA). They have now become the standard for doctors, coders, patients, and insurance companies to label and identify medical services and procedures.

Why Are CPT Codes so Important?

CPT codes are of primary importance for a few different reasons:

  1. They are used by insurers to determine the amount of reimbursement a practitioner will receive under your health insurance coverage (and ultimately how much of the bill you will be left responsible for).
  2. As a continuation of #1, they are used by insurers to determine whether or not a particular procedure is deemed to be wellness or illness related – particularly important if you have a high deductible plan.
  3. They can be used by you to diagnose medical billing errors.
  4. They can be used by you to find out exactly what type of diagnostic, medical, or surgical work your physician has requested for you.

Important stuff.

What to do when you Come Across a CPT Code

When your primary care physician orders up work to be done by others, hopefully they will have a conversation with you about exactly what that work will be.

They will then send you off with a piece of paper that indicates exactly what that work is. On that piece of paper will be a set of 5-digit CPT codes.

Any time you encounter this or a similar scenario, I would recommend:

  1. Confirm the CPT Code: Finding out if all the codes were entered correctly so that you do not have work done you were not expecting. If your physician didn’t cover exactly what work they were requesting, you have a right to find out why they requested it in the first place.
  2. Get the Best Price: Contact your health insurer to find out if the service is considered wellness preventative and is covered entirely by your plan. If it is not, insurers have pre-negotiated rates with practitioners and some may have lower prices than others.

How to do a CPT Code Search

You will not be able to find a free published list of CPT codes anywhere as the AMA owns the copyrights and charges licensing fees to those who publish them. Third parties do publish them, but they charge for access to the list.

I was able to get a list of preventative CPT codes for my health insurance plan from my employer’s benefits department. You may be able to do the same.

You can also search by keyword or 5-digit code via the AMA’s CPT code search.

Lessons Learned on CPT Codes

Going back to the billing dispute I mentioned earlier will highlight the importance of CPT codes. My wife and I had gone in for annual physical exams and our physician ordered up blood work. We didn’t think anything of it, got our blood drawn, and then were hit with $612 in bills.

What I found after months of digging was that four of the CPT codes on the blood tests ordered by our physician were not covered by my HDHP as wellness preventative. I was able to cut off $493 of preventative blood work from the bill because my health insurer had incorrectly charged all of the blood work as non-preventative, illness related. I still had to foot the bill for the $119 that was considered preventative.

Lessons learned from this experience:

  1. Had I called the insurer ahead of time to run the CPT codes by them, I would have known what was considered preventative and what was not. The ones that were not preventative, I could have asked my doctor why they were ordered and if it was necessary. This also would have tipped me off as to what my bills should be so I could compare them to my actual bills when they arrived.
  2. If certain work was still necessary, I could have asked the insurer where I could have received the lowest rate to get that blood work done – this would have resulted in lower costs than $119.
  3. Always question your medical bills. This saved me $493 on simple blood work.

I know this sucks and sounds a bit painful, but this is the state of our screwed up health care system. The more you understand the language and how your doctor is communicating with practitioners and insurers, the more money you’ll save. And CPT codes are at the center of all of it.

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10 Comments »
  • Ryan DeLeon says:

    I started questioning just about every bill I get. Started with almost the exact situation, routine blood work turns into a $600 bill. I called and they told me “something was coded wrong”, and it ends up being a $90 bill. Since then I usually send anything over $100 back and write “re-run through insurance”, and somehow it magically comes back significantly lower. It’s like they start high, hope you don’t complain, then cave when you do. But hey, if 50% of the people don’t complain and you charge them 75% more, win right?

    • G.E. Miller says:

      Isn’t that funny… I thought the same thing about hoping you don’t catch it and then lowering when they know they’ve been had. It’s clear that some better industry regulation is needed.

      • RNT says:

        I can verify that. Every single time I need something done that requires medical insurance, it costs more than you might think, I complain, and then it magically gets lowered. Complaining, questioning or asking for review is now my default action whenever I get anything from my insurance company. Over the past 2 years, this action has saved me literally multiple thousands of dollars.

        • G.E. Miller says:

          I even had a billing specialist at my doctor tell me that this is their strategy. The more you complain, the more it magically gets lowered. And they try to wear you down by giving you a hard time. I know there’s a big anti-govt. push right now, but when an entire industry is intentionally over-inflating their bills in the hopes you don’t complain, why isn’t the govt. getting involved?

          • Ryan DeLeon says:

            I agree, there is really no other industry ran like this. Where else do you go in for service, they give you no indication of how much it will cost (even when you ask), then send you a bill months later and expect you to pay immediately. Most people cannot budget for that. Also, no other service could get away with that.

  • Ron Ablang says:

    I have had my HDHP w/ HSA for almost 3 years now. I have had babies born in 2 of the last 3 years so I have hit the max deductible for those years.

    Since I won’t be hitting the max as often in the future, I shall need to question every single bill from 2013 and on since this overcharging scheme seems to be a pattern.

  • Keri says:

    Many public libraries will have a copy of CPT in their reference collection. Probably not the very small libraries, but if you have a main branch or a larger town nearby.

    Search your catalog for Current Procedural Terminology if CPT doesn’t work. And if you can’t find it on the shelf, ask a librarian. We keep ours in our ready reference collection behind the reference desk because it’s one that unfortunately might get stolen on the public shelves.

  • Andy says:

    One other major component to a medical claim that I want to point out is the diagnosis code. All providers are required to indicate a diagnosis code (reason for the services). Many CPT codes can either be diagnostic or routine in nature and the final determination will be made by which diagnosis code is billed in conjuction with it. However, most insurance companies will not disclose this as it often leads to questions or disputes as to why the services were rendered. As a result, in order to get it, you most likely have to call the doctor’s office.

    I’ve worked on both sides in the industry (insurance company and doctor’s office) and honestly have found errors equally on both sides. Often the insurance compnany finds ways to give you more money is because the claim was most likely processed by a system and not a human and that’s where the errors came from. Additionally, providers often up bill in hopes that the insurance compnay or consumer won’t catch it. They also often struggle to grasp the concept that diagnosis codes and CPT codes are inter-related. Hope this helps you all.

  • Jessica says:

    Hello,

    This question is not related at all to CPT codes but I found your website while doing some researching on Ooma phone service. I saw your review and it was from a few years ago and I’m wondering if you still have it and what your thoughts are now on it?? I’m finding so many mixed reviews I’m not sure whether to switch or not.

    Thank you!

  • Danielle says:

    I like the promotion of people advocating for their healthcare benefits by learning about medical/medical insurance jargon. It seems one thing not mentioned in the article is the use of ICD-9/10 codes (diagnosis codes). These codes are used in conjunction with the CPT codes. Together they determine if you provider’s medical claim is payable. For instance, if you have a diagnosis code of a wellness (annual physical) and your CPT code presents something for a sickness, lets just say removal of skin lesion, your claim’s benefits are set to the lowest of the two as the ten codes are in conflict. Also the insurance company can request the medical notes to see why this is conflicting if they want. If the same scenario occurs and you do not have wellness (routine-without the presence of injury, sickness or disease) benefits your claim is likely to be denied. There are so many other things to consider as well: does your policy accept creditable coverage if they have a pre-existing clause or do they not accept it at all? Is the diagnosis one of the exclusions in your policy and CPT codes not matter in this instance? Does your policy just not provide benefits for this service? Is there a dollar limit on procedure?Did you exhaust your benefits? Did you obtain the appropriate authorizations? And two very common ones, did the biller make a mistake? Did the claims adjuster make a mistake? I could go on and on forever, but I’ll stop here…

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