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What Is a CPT Code With a Modifier?

CPT stands for current procedural terminology. CPT codes describe medical, surgical and diagnostic services performed by medical personnel and communicate accurate, uniform information about the medical service or procedure. For example, the code for vaccine administration communicates that an immunization was performed but also which vaccine. Modifiers tell the insurance company about a deviation from the normal description associated with the CPT code.

  1. History

    • Nathan Smith Davis, M.D. established the American Medical Association in 1847, just one year after he began serving as a member of the New York Medical Society. His dream was to increase the standard of medical education throughout the United States. The American Medical Association published the first manual of CPT codes in 1966 in order to standardize the language used by medical practitioners concerning health situations. Since then, they have been the standard in medical coding and billing.

    CPT Codes

    • Use of machines has a related CPT code.

      There are several types of CPT codes. The code a primary care physician uses for an office visit is different from the one a heart surgeon uses. Hospitals also have their own codes, describing every service given to a patient. Each type of service has a code book containing codes that pertain to the services they provide.

    Modifiers

    • Many times, the description in the CPT code book does not adequately describe the service the physician or hospital provided. Perhaps a patient fell and needs a splint on each wrist because both wrists were sprained. If the CPT code used describes only a single sprain, the physician's office would use a modifier with the CPT code to tell the insurance company that two splints were provided. Or perhaps a physician discovers a bilateral injury where he suspected a single. He uses a modifier with the CPT code to tell the insurance company of the change.

    Medical Reimbursements

    • With CPT codes and modifiers, physicians, coders, patients, hospitals, technical staff, accreditation organizations and insurance companies all talk the same language and understand the services provided. Insurance companies use these codes to determine how much to reimburse the physician for the service they provided.

    Changes to the Codes

    • Several times a year, the AMA CPT panel meets to discuss health care changes. They revise existing codes or develop new codes for new services. Addendums to the code book are released when necessary, and the entire CPT code book is updated and reissued annually.

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