Difference between ICD-10-CM, CPT, ICD-10-PCS, HCPCS coding

Medical codes are divided into 4 different categories ICD-10-CM, CPT, ICD-10-PCS, HCPCS coding. So what is the reason for 4 different sets instead of one? The below article deals with the fine differentiation between the 4 sets of codes and what each division is exclusively used for.

ICD-10-CM

ICD-10 - International Statistical Classification of Diseases and Related Health Problems

ICD-10 was implemented in October 2015 by CMS, this revision and replacement of ICD-10 include codes for diseases, symptoms, abnormal findings, conditions, circumstances and external causes of injury or diseases.  ICD is the international standard for reporting diseases and health conditions including monitoring of disease. WHO is in charge of implementing ICD-10. The ICD-10-CM is a clinical modification system used exclusively for recording US healthcare.

 ICD-10 comprises of two divisions:

• ICD-10-CM (Clinical Modification) which is used primarily for diagnosis coding in all healthcare settings.  It has about 68,000 codes.

• ICD-10-PCS (Procedure Coding System) is used only for coding hospital inpatient procedures.  It consists of about 76,000 codes.  

The above divisions are used only in the US healthcare setting.

When people mention ICD-10, they are referring to ICD-10-CM.   

An example of an ICD-10 code is E05.0 – Thyrotoxicosis with diffuse goiter

CPT - Current Procedural Terminology

CPT codes are the codes used for reporting surgeries and minor procedures and getting paid. When a claim is filed with the CPT procedure code along with the appropriate ICD-10 diagnosis code, payment is made to the providing practitioner. 

 Example:  CPT codes are essential for getting payment from insurance.

Code 11600 specifies that an excision was done for a malignant lesion including margins and the lesion can be situated either in the trunk, arms or legs and the lesion was 0.5 cm or less.

The CPT system is maintained and implemented by the American Medical Association.

There are three categories of CPT codes:

CPT - used for reporting claims and getting paid. This may be an office visit or Emergency department visit. The correct code level is selected based on some set criteria. The most important factor in determining the level of code is whether the patient in question is a New patient or an already Established one.

• Example, reporting code 99285 will get you payment for an Emergency department visit.

CPT II – Set of supplemental tracking codes that can be used for performance measurement.  Example, reporting 2000F will inform the payer that during the 99285 Emergency Department visit above, blood pressure assessment was also done.  Often these codes are not recorded because they do not generate revenue.

Category III – These codes are not federally regulated and are fairly new to the healthcare industry.  They are reported to help health facilities and government agencies track the efficacy of new, nascent medical techniques. Using Category III codes is important as it keeps the medical fraternity up to date with new cutting-edge developments and medical breakthrough technology. 

HCPCS - Healthcare Common Procedures Coding System

HCPCS codes are used to report supplies, equipment, and devices provided to patients as well as procedures not contained in the CPT code system. It is an additional or supplemental resource to CPT codes. HCPCS codes are referred to as Level II CPT codes. HCPCS is alphanumeric and is implemented by the Centers for Medicare and Medicaid Services (CMS) 

 CMS includes two levels in its Healthcare Common Procedures Coding System: 

• HCPCS Level I codes is the CPT coding system. (Both are one and the same)
• HCPCS Level II codes are usually referred to as HCPCS codes.

Level I of the HCPCS comprises of Current Procedural Terminology (CPT), a numeric coding system maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals usually in the outpatient setting. These health care professionals use the CPT to identify services and procedures for which they bill public or private health insurance programs. Level I of the HCPCS, the CPT codes, does not include codes needed to separately report medical items or services that are regularly billed by suppliers other than physicians.

Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies when used outside a physician's office. Because Medicare and other insurers cover a variety of services, supplies, and equipment that are not included in CPT codes, the level II HCPCS codes were established for submitting claims for these items.”

 “Coders use HCPCS codes to represent medical procedures to the insurance companies. The code set is divided into three levels. Level I is identical to CPT, though technically those codes, when used to bill Medicare or Medicaid, are HCPCS level I codes. Level II HCPCS codes are used to represent non-physician services like ambulance rides, wheelchairs, walkers, other durable medical equipment and other medical services that are not included in CPT. HCPCS Level II takes care of medicinal products and pieces of medical equipment (DME – durable medical equipment) which are not included in CPT.”

When you are faced with ambiguity as to which code to use -- CPT or HCPCS codes as these 2 sets are very much related and similar, follow the below rule

• When both a CPT and an HCPCS Level II code have exactly identical content for a procedure or service, use the CPT code. If, however, the description is not identical and slightly different, use the HCPCS Level II code.
• Check for an HCPCS national code when a CPT code description contains an instruction to include additional information, such as describing a specific medication. When the medication dosage plays an important role in the description, you can use HCPCS codes as they generally add more specificity in terms of dosages of medication.

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