Professional CPT Coding for Medical Procedures & Services
CPT coding identifies medical procedures and physician services provided during patient visits. Using AMA-approved CPT codes, we ensure accurate billing, proper reimbursement, and reduced audit risk.
Complete Guide to CPT Codes and Medical Procedure Coding
CPT (Current Procedural Terminology) coding is used to report medical procedures and physician services performed during patient encounters. Accurate CPT coding is essential for correct reimbursement and compliance with payer policies.
Maintained by the American Medical Association (AMA), CPT codes define services such as office visits, diagnostic tests, and surgical procedures. Our expert coders ensure each service is coded accurately based on documentation, modifiers, and payer-specific rules.
Benefits of Accurate CPT Coding
Most Commonly Used CPT Codes by Specialty
Evaluation and Management (E/M) Codes
Evaluation and Management codes are among the most frequently used CPT codes in medical billing. These codes document patient visits across various healthcare settings.
Office or Outpatient Visit - New Patient:
| Code | Description | ||
| 99202 | Office visit | new patient | straightforward medical decision making (15-29 minutes) |
| 99203 | Office visit | new patient | low level of medical decision making (30-44 minutes) |
| 99204 | Office visit | new patient | moderate level of medical decision making (45-59 minutes) |
| 99205 | Office visit | new patient | high level of medical decision making (60-74 minutes) |
Office or Outpatient Visit - Established Patient:
| Code | Description | ||
| 99211 | Office visit | established patient | minimal service (typically nurse visit) |
| 99212 | Office visit | established patient | straightforward medical decision making (10-19 minutes) |
| 99213 | Office visit | established patient | low level of medical decision making (20-29 minutes) |
| 99214 | Office visit | established patient | moderate level of medical decision making (30-39 minutes) |
| 99215 | Office visit | established patient | high level of medical decision making (40-54 minutes) |
Hospital Inpatient Services:
| Code | Description | |
| 99221 | Initial hospital care | straightforward or low level decision making |
| 99222 | Initial hospital care | moderate level of medical decision making |
| 99223 | Initial hospital care | high level of medical decision making |
| 99231 | Subsequent hospital care | straightforward or low level decision making |
| 99232 | Subsequent hospital care | moderate level of medical decision making |
| 99233 | Subsequent hospital care | high level of medical decision making |
| 99238 | Hospital discharge day management | 30 minutes or less |
| 99239 | Hospital discharge day management | more than 30 minutes |
Hospital Inpatient Services:
| Code | Description | |
| 99281 | Emergency department visit | straightforward medical decision making |
| 99282 | Emergency department visit | low level of medical decision making |
| 99283 | Emergency department visit | moderate level of medical decision making |
| 99284 | Emergency department visit | moderate to high level of medical decision making |
| 99285 | Emergency department visit | high level of medical decision making |
| 99241-99245 | Office consultation codes (new or established patient) | |
| 99251-99255 | Initial inpatient consultation codes | |
Preventive Medicine Codes
Preventive medicine services include routine physical examinations and preventive care visits.
| Code | Description | |
| 99381 | Initial comprehensive preventive medicine | infant (younger than 1 year) |
| 99382 | Initial comprehensive preventive medicine | early childhood (1-4 years) |
| 99383 | Initial comprehensive preventive medicine | late childhood (5-11 years) |
| 99384 | Initial comprehensive preventive medicine | adolescent (12-17 years) |
| 99385 | Initial comprehensive preventive medicine | 18-39 years |
| 99386 | Initial comprehensive preventive medicine | 40-64 years |
| 99387 | Initial comprehensive preventive medicine | 65 years and older |
Preventive Medicine - Established Patient:
| Code | Description | |
| 99391 | Periodic comprehensive preventive medicine | infant (younger than 1 year) |
| 99392 | Periodic comprehensive preventive medicine | early childhood (1-4 years) |
| 99393 | Periodic comprehensive preventive medicine | late childhood (5-11 years) |
| 99394 | Periodic comprehensive preventive medicine | adolescent (12-17 years) |
| 99395 | Periodic comprehensive preventive medicine | 18-39 years |
| 99396 | Periodic comprehensive preventive medicine | 40-64 years |
| 99397 | Periodic comprehensive preventive medicine | 65 years and older |
Laboratory and Pathology Codes
Common Laboratory Procedures:
| Code | Description | |
| 80053 | Comprehensive metabolic panel | |
| 80061 | Lipid panel | |
| 81001 | Urinalysis | automated with microscopy |
| 82947 | Glucose | blood quantitative |
| 83036 | Hemoglobin A1C level | |
| 84443 | Thyroid stimulating hormone (TSH) | |
| 85025 | Complete blood count (CBC) with differential | |
| 85027 | Complete blood count (CBC) | automated |
| 86580 | TB skin test (tuberculin skin test) | |
| 87086 | Urine culture | bacterial |
| 87880 | Strep test | rapid |
Radiology and Imaging Codes
| Category | Code | Description | ||
| X-Ray Services | 71045 | Chest X-ray | single view | |
| X-Ray Services | 71046 | Chest X-ray | 2 views | |
| X-Ray Services | 73030 | Shoulder X-ray | complete | |
| X-Ray Services | 73060 | Humerus X-ray | complete | |
| X-Ray Services | 73562 | Knee X-ray | 3 views | |
| X-Ray Services | 73610 | Ankle X-ray | complete | |
| CT and MRI Scans | 70450 | CT head or brain without contrast | ||
| CT and MRI Scans | 70553 | MRI brain without contrast | followed by contrast | |
| CT and MRI Scans | 71250 | CT thorax without contrast | ||
| CT and MRI Scans | 72148 | MRI lumbar spine without contrast | ||
| CT and MRI Scans | 74160 | CT abdomen with contrast | ||
| CT and MRI Scans | 74177 | CT abdomen and pelvis with contrast | ||
| Ultrasound Services | 76700 | Ultrasound | abdominal | complete |
| Ultrasound Services | 76705 | Ultrasound | abdominal | limited |
| Ultrasound Services | 76805 | Ultrasound | pregnant uterus | complete |
| Ultrasound Services | 76856 | Ultrasound | pelvic | complete |
| Ultrasound Services | 93306 | Echocardiography | complete | |
Common Anesthesia Codes:
| Code | Description |
| 00100 | Anesthesia for procedures on salivary glands |
| 00400 | Anesthesia for procedures on the integumentary system |
| 00532 | Anesthesia for access to central venous circulation |
| 00790 | Anesthesia for intraperitoneal procedures in upper abdomen |
| 00840 | Anesthesia for intraperitoneal procedures in lower abdomen |
| 00902 | Anesthesia for anorectal procedure |
| 01967 | Anesthesia for cesarean delivery following neuraxial labor analgesia |
Medicine Codes:
| Category | Code | Description | ||
| Immunizations and Vaccines | 90460 | Immunization administration | first vaccine component | |
| Immunizations and Vaccines | 90461 | Immunization administration | each additional vaccine component | |
| Immunizations and Vaccines | 90471 | Immunization administration | one vaccine | |
| Immunizations and Vaccines | 90472 | Immunization administration | each additional vaccine | |
| Immunizations and Vaccines | 90633 | Hepatitis A vaccine | ||
| Immunizations and Vaccines | 90680 | Rotavirus vaccine | ||
| Immunizations and Vaccines | 90686 | Influenza vaccine | quadrivalent | |
| Immunizations and Vaccines | 90707 | MMR vaccine (measles | mumps | rubella) |
| Immunizations and Vaccines | 90715 | Tdap vaccine (tetanus | diphtheria | pertussis) |
| Cardiac and Pulmonary Services | 93000 | Electrocardiogram with interpretation | ||
| Cardiac and Pulmonary Services | 93015 | Cardiovascular stress test | ||
| Cardiac and Pulmonary Services | 93306 | Echocardiography | transthoracic | |
| Cardiac and Pulmonary Services | 94010 | Spirometry | ||
| Cardiac and Pulmonary Services | 94060 | Bronchodilation responsiveness | ||
| Cardiac and Pulmonary Services | 94664 | Aerosol or vapor inhalation treatment | ||
| Physical Medicine and Rehabilitation | 97110 | Therapeutic exercises | ||
| Physical Medicine and Rehabilitation | 97112 | Neuromuscular reeducation | ||
| Physical Medicine and Rehabilitation | 97140 | Manual therapy techniques | ||
| Physical Medicine and Rehabilitation | 97161 | Physical therapy evaluation | low complexity | |
| Physical Medicine and Rehabilitation | 97162 | Physical therapy evaluation | moderate complexity | |
| Physical Medicine and Rehabilitation | 97163 | Physical therapy evaluation | high complexity | |
Why Accurate CPT Coding Matters
CPT Coding Best Practices
Documentation Requirements
Proper documentation is the foundation of accurate CPT coding. Medical records should clearly describe:
- Chief complaint and reason for visit
- History of present illness
- Review of systems
- Past medical, family, and social history
- Physical examination findings
- Medical decision making
- Assessment and plan
- Time spent on encounter (when applicable)
- Procedures performed with detailed description
Staying Current with Updates
The AMA updates CPT codes annually, typically effective January 1st. These updates include new codes, revised codes, and deleted codes. Staying current with these changes is essential for accurate coding and optimal reimbursement.
Understanding Payer Policies
Different insurance payers have varying policies regarding CPT code coverage, bundling rules, and documentation requirements. Our team maintains knowledge of payer-specific guidelines to maximize clean claim rates.
Proper Use of E/M Guidelines
The 2021 E/M guideline changes significantly altered how office visit codes are selected. Understanding medical decision making levels and time-based coding is crucial for accurate E/M coding.
Contact Us for Professional CPT Coding Services
Our team of certified professional coders brings extensive experience across all medical specialties. We understand the complexities of CPT coding and work diligently to ensure your practice receives accurate reimbursement while maintaining compliance.
Whether you need ongoing coding support, coding audits, provider education, or help with specific specialty coding challenges, our experts are ready to assist your practice in achieving coding excellence.
Transform Your Medical Billing with Expert CPT Coding
Whether you need ongoing coding support, coding audits, provider education, or help with specific specialty coding challenges, our experts are ready to assist your practice in achieving coding excellence.
