Difference Between CPT and HCPCS

Have you ever wondered how doctors and hospitals bill for your healthcare? It is all determined by special code language; it is basically the language that healthcare and insurance companies use. Two of the most important codes in this system are CPT and HCPCS. But what exactly do they mean, and how are they different? Let us break down these medical codes to understand them.

Consider CPT and HCPCS to be Medical-Service Filing Cabinets.

Each code acts like a label, telling the insurance company precisely what kind of service was provided. This ensures everyone is on the same page, and the doctor gets paid for their work.

Key Differences Between CPT and HCPCS Codes

Here’s the key difference:

Development and Ownership

  • CPT codes are developed and maintained by the American Medical Association (AMA).
  • HCPCS codes are developed and maintained by the Centers for Medicare & Medicaid Services (CMS).

CPT (Current Procedural Terminology)

This codebook focuses on physician services. It includes things like office visits, surgeries, X-rays, and other procedures doctors perform. Consider it the main cabinet for all the doctor’s work. CPT codes are entirely numeric, with five digits each.

Examples

  • 99214 – Office visit.
  • 90658 – Administration of a flu shot.
  • 99397 – Preventive exam (over the age 65).

HCPCS (Healthcare Common Procedure Coding System)

This codebook is more extensive. It includes everything CPT does, plus additional services and supplies. Consider it an overflow cabinet for things that do not fit neatly in the CPT cabinet. HCPCS codes are alphanumeric, meaning they use a letter followed by four numbers.

Examples

  • V2599 – Contact lens, other type.
  • A0425 – Ambulance transportation (ground mileage).
  • G9631 – Ureteric injury during time of surgery or discovered up to 30 days post-surgery.

Here’s a table to summarize the key differences:

Feature CPT HCPCS                                           
Focus Physician services           Physician services, supplies, and other services          
Structure    5-digit numeric code Alphanumeric code (letter + 4 numbers)
Example 99213 (office visit) A4648 (walking cast)

CPT

This one is all about the doctor’s work. It has codes for:

  • Evaluation and Management Services: These codes represent check-ups, consultations, and other times the doctor spends evaluating your health.
  • Procedures: This section includes surgeries, biopsies, injections, and other medical procedures performed by doctors.
  • Medicine Administration: These codes represent giving you medications during a visit.

HCPCS

This one holds everything else, including:

  • Level I HCPCS: This level actually mirrors the CPT codes, making it easier for doctors to switch between them.
  • Level II HCPCS: Here you will find codes for:
    • Durable Medical Equipment (DME): Think wheelchairs, walkers, and other equipment you need at home.
    • Drugs and Biologicals: These codes represent specific medications and vaccines not covered by regular CPT codes.
    • Other Services and Supplies: This includes anything from ambulance rides to splints and bandages.

Check out the list of the several interpretations for the alphabetical letters that follow in a level II HCPCS code:

  • A Codes – Transportation, surgical supplies, medical supplies, misc & experimental.
  • B Codes – Parenteral and enteral therapy.
  • C Codes – Temporary outpatient hospital prospective payment system.
  • D Codes – Dental procedures. 
  • E Codes – Durable medical equipment.
  • G Codes – Professional services and temporary procedures.
  • H Codes – Rehabilitative services.
  • J Codes – Drugs administered (other than oral methods and chemotherapy drugs).
  • K Codes – Temporary codes for durable medical equipment regional carriers.
  • L Codes – Prosthetic or orthotic procedures.
  • M Codes – Medical services.
  • P Codes – Laboratory and pathology.
  • Q Codes – Temporary codes.
  • R Codes – Diagnostic radiology.
  • S Codes –  Private payer codes.
  • T Codes – State Medical agency codes.
  • V Codes – Vision and hearing.

Copyright

  • CPT codes are copyrighted by the AMA.
  • HCPCS codes are not copyrighted and are in the public domain.

Complexity

CPT codes are generally less complex than HCPCS codes, especially Level II codes.

Why are there Two Codebooks?

CPT is the doctor’s personal codebook, focusing on their services. HCPCS is a more universal codebook that expands on CPT to include everything else involved in your care. This ensures everyone involved (doctor, hospital, insurance) is using the same language for billing.

Who Uses these Codes?

Medical coders work behind the scenes, translating what doctors perform into these codes. They verify that the appropriate codes are used for accurate invoicing. Understanding these codes can also be beneficial to patients because it allows them to better understand what services they are being billed for. 

Conclusion

Understanding these codes is not necessary for everyday living, but it can help anyone become a more informed healthcare consumer. Knowing the basics of CPT and HCPCS can help you better understand how your medical care is billed.

FAQs

  1. I see both CPT and HCPCS codes on my bill. What does that mean?

This is normal! CPT codes represent the doctor’s services (checkups, procedures), while HCPCS codes cover additional services and supplies used during your care (durable medical equipment, vaccines). 

  1. Are the CPT and HCPCS codes the same for everyone?

CPT codes are generally universal across healthcare providers. HCPCS codes, however, might vary slightly depending on the specific insurance company’s requirements. However, the meaning of the code itself remains consistent.

  1. Why are there two different coding systems?

CPT focuses specifically on what the doctor does, while HCPCS provides a broader picture of all the resources used in your care. This two-pronged approach ensures accurate billing for all aspects of your medical service.

  1. Do I need to memorize all these codes?

Not necessarily! While understanding the basic difference between CPT and HCPCS empowers you to review your bills, memorizing codes is not necessary. If you have any questions about a specific code, contacting your healthcare provider or insurance company can provide clarification.

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