HCPCS vs CPT: Unveiling the 6 Key Differences (2024) - Streamline Health (2024)

When it comes to medical coding, two terms that are frequently used are HCPCS and CPT. While they may sound similar, understanding the difference between these two coding systems is crucial for accurate billing.

HCPCS stands for Healthcare Common Procedure Coding System and is used to classify medical procedures and services. Meanwhile, CPT, or Current Procedural Terminology, is used to describe medical procedures and services.

While they are both used in medical coding, the codes and descriptions used in each system are different. Therefore, it is important to understand the difference in coding rules used between HCPCS and CPT to ensure that medical procedures and services are appropriately coded and billed.

What is the difference between HCPCS and CPT codes?

The difference between the CPT coding system and HCPCS codes lies primarily in their purpose, structure, and usage. CPT (Current Procedural Terminology) is a five-digit numeric code used universally by healthcare providers to report medical, surgical, and diagnostic services for billing purposes. CPT codes are developed and owned by the American Medical Association.

On the other hand, HCPCS (Healthcare Common Procedure Coding System) is alphanumeric and comes in two primary levels and a third local level. Level I HCPCS codes are also known as CPT-4 (Edition 4) codes, while Level II are used to identify products, supplies, and services not included in the CPT standardized coding system, primarily for Medicare and Medicaid. HCPCS codes are owned in the public domain created by Centers for Medicare and Medicaid Services.

CPT Codes

CPT, or Current Procedural Terminology, is a medical code set used to report medical, surgical, and diagnostic procedures and services. Developed and maintained by the American Medical Association (AMA), CPT codes are a critical component of the healthcare industry, serving as a uniform language for communicating information about medical services and procedures.

Overview of CPT Code Structure

CPT codes are five-digit numeric codes. They are divided into three categories:

1. Category I: These are the most commonly used CPT codes and describe most of the healthcare services and procedures performed by healthcare providers. They are divided into six main sections: Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology, Laboratory, and Medicine.
2. Category II: Category II are optional performance measurement codes that provide information about the quality of care delivered. They are typically used for data collection, measurement, and analysis.
3. Category III: Category III are temporary codes used for emerging and experimental services, procedures, and technologies.

HCPCS codes

HCPCS, or Healthcare Common Procedure Coding System, is a set of healthcare procedure codes based on the American Medical Association’s Current Procedural Terminology (CPT). Developed by the Centers for Medicare and Medicaid Services (CMS), HCPCS codes are used to report medical procedures and services to Medicare, Medicaid, and other health insurance programs.

Overview of HCPCS Code Structure

HCPCS codes are alphanumeric and are divided into two levels primary levels and a third locally used level:

1. Level I: These are also known as CPT-4 and are used for reporting services and procedures performed by physicians.
2. Level II: These codes are used to identify products, supplies, and services not included in the CPT codes, such as ambulance service, durable medical equipment, prosthetics, orthotics, and supplies.
3. Level III: Level III HCPCS codes are not accepted nationally and are instead used locally. They are a combination of letters and numbers, with the code always starting with either the letter X or Z. They have been discontinued nationally as of 2003.

HCPCS vs CPT: Examples of Differences

While HCPCS and CPT often overlap, there are instances where they differ significantly, particularly when it comes to Level II HCPCS.

HCPCS Examples:

• Medical Equipment: If a patient receives a semi-electric hospital bed as part of their treatment, this would be coded using the HCPCS Level II E0260. There is no equivalent CPT for this item, as they primarily cover medical, surgical, and diagnostics rather than equipment.
• Non-Covered Service: If a service or item is not covered by Medicare or Medicaid, it would be coded using the HCPCS Level II A9270. Again, there is no equivalent CPT for this, as CPT does not include provisions for non-covered service.
• Ambulance Service: If a patient requires ambulance transportation, this would be coded using an HCPCS Level II code, such as A0425 for ground mileage. CPT does not cover ambulance service.

CPT Examples:

• 99213: This code is used for an office or other outpatient visit for the evaluation and management of an established patient. There are no equivalent HCPCS Level II codes for this service, as it falls under the medical, surgical, and diagnostic services covered by CPT.
• 20610: This code is used for aspiration and/or injection of a large joint or joint capsule. There is no equivalent HCPCS Level II code for this procedure, as it is specifically covered under the surgical services in CPT.
• 71020: This code is used for a chest X-ray. There are no equivalent HCPCS Level II codes for this diagnostic service, as it is covered under the radiology services in CPT.

These examples illustrate the key differences between HCPCS and CPT in practical applications.

Key Differences between HCPCS and CPT

Why is Knowing the Difference between HCPCS and CPT standardized coding system important?

Knowing the difference between HCPCS and CPT codes is crucial for a multitude of reasons, particularly in the realm of medical services. These coding systems serve as the backbone of medical billing, directly impacting the financial health and human services of healthcare providers, and the accuracy of patient invoices.

1. Accurate Billing and Reimbursem*nt: HCPCS and CPT codes are used to represent the medical, surgical, and diagnostic services provided to a patient. Each code corresponds to a specific service, and the correct use of these codes ensures that healthcare providers are accurately reimbursed for their services. Misunderstanding or misusing them can lead to underpayment or overpayment, and in some cases, legal issues related to fraud.
2. Efficient Communication: These codes provide a standardized language for documenting and communicating medical services across various stakeholders, including healthcare providers, insurance companies, and patients. This uniformity facilitates efficient communication and reduces the chances of misunderstandings or errors.
3. Data Analysis and Research: HCPCS and CPT codes are also essential tools for medical research and public health data analysis. They allow researchers to identify trends in healthcare services, track the prevalence of specific procedures, and study healthcare costs. This data can inform policy decisions and contribute to the improvement of healthcare services.
4. Regulatory Compliance: Compliance with regulations such as the Health Insurance Portability and Accountability Act (HIPAA) is another critical reason for understanding these codes. HIPAA and other regulations require standard codes like HCPCS and CPT for electronic healthcare transactions.

Conclusion

In conclusion, medical coding professionals must understand the difference between HCPCS and CPT code systems. These code sets provide the standard language for medical procedures and services, making it easier for healthcare providers, insurers, and patients to communicate.

HCPCS codes, which include “H,” “J,” “K,” and “L” codes, are used to report medical supplies, equipment, and services not included in CPT codes. Therefore, coders need to understand the scope of these codes and use them appropriately for accurate reimbursem*nt. CPT codes, on the other hand, cover all medical procedures and services covered by insurance, making it essential for medical coders to have a thorough knowledge of them to ensure the right code is assigned to the right service.

By understanding the importance of HCPCS vs. CPT, medical billers and medical coders can help ensure accurate billing of health claims and proper reimbursem*nt, benefiting both providers and patients alike.