CPT Codes: Why you NEED to know what they are
“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 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:
- 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).
- 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.
- They can be used by you to diagnose medical billing errors.
- They can be used by you to find out exactly what type of diagnostic, medical, or surgical work your physician has requested for you.
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:
- 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.
- 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:
- 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. Is it a pain? Sure. But you should still do it.
- 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.
- 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.