What Are CPT Codes?
CPT (Current Procedural Terminology) codes are five-character codes that describe specific medical procedures, tests, and services. CPT codes are owned by the American Medical Association and updated annually. Every medical claim is coded with a CPT code (or multiple codes for complex procedures).
Understanding CPT codes helps you research your coverage: you can determine whether a specific procedure is covered by your plan, check whether prior authorization is required, and understand what your insurer will likely approve or deny.
Understanding CPT Code Structure
CPT codes are 5-digit numbers (e.g., 99213 is an office visit code, 70553 is an MRI brain code). Each code corresponds to one specific procedure. CPT codes are organized into categories: Office/Outpatient (99200-99499), Hospital (99217-99239), Consultations (99241-99255), Procedures (10000-99607), and others.
Your insurance claim paperwork includes the CPT code for each service. Finding your procedure's CPT code is essential for researching coverage.
Finding Your Procedure's CPT Code
Ask your healthcare provider's office for the CPT code for your planned procedure. If you don't know your code, ask during the appointment or check previous bills. Once you have the code, you can research coverage in your plan documents.
Check your plan's summary of benefits and coverage (SBC) document for CPT code-specific coverage information. Call your insurance company and ask specifically whether the CPT code is covered and whether prior authorization is required.
Using CPT Codes for Coverage Research
Many insurance companies provide online tools allowing you to search coverage by CPT code. Some plans show coverage details (authorization required? coverage percentage? applicable limits?) for specific codes. This research prevents surprises when claims are denied.
If your plan denies a claim and codes a procedure differently than submitted, check whether the reimbursed code differs from the billed code. Code errors sometimes explain denials.
Investigating Coverage Denials Using CPT Codes
If a claim is denied, verify that the correct CPT code was billed. Sometimes similar procedures have different codes with different coverage. Confirm that your plan covers the billed CPT code. If the code is covered but the claim was denied, investigate the denial reason — prior authorization, medical necessity, frequency limit, etc.