Health Data Standards and Terminologies A Tutorial

2: Terminology Standards and Tools


CPT


nurse preparing patient for a tomography exam at hospital at hospital

(Image Source: iStock Photos, FG Trade LatinĀ©)

CPT (Current Procedural Terminology) is a commonly used clinical terminology developed by the American Medical Association (AMA) in 1966. It is a national coding standard mandated by HHS under the Health Insurance Portability and Accountability Act (HIPAA).

The CPT codes offer healthcare professionals a uniform language for coding medical services and procedures to streamline reporting and increase accuracy and efficiency. CPT codes are also used for administrative management purposes such as claims processing and developing guidelines for medical care review.

The CPT terminology is the most widely accepted medical nomenclature used across the U.S. to report medical, surgical, radiology, laboratory, anesthesiology, genomic sequencing, evaluation, and management (E/M) services under public and private health insurance programs.

Here are some examples of CPT codes:

  • Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed (77067)
  • Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]); screen (86408)
  • Placement of choledochal stent (47801)
  • Radiologic examination, teeth; single view (70300)

References

"CPT (CPT - Current Procedural Terminology)." Unified Medical Language System (UMLS), U.S. National Library of Medicine, www.nlm.nih.gov/research/umls/sourcereleasedocs/.

"CPT Overview and Code Approval." American Medical Association, www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval#:~:text=The%20Current%20Procedural%20Terminology%20(CPT,reporting%2C%20increase%20accuracy%20and%20efficiency.

"CPT Purpose & Mission." American Medical Association, www.ama-assn.org/about/cpt-editorial-panel/cpt-purpose-mission.

"CPT: The Shared Language of Health Care." American Medical Association, 21 Nov. 2022, www.ama-assn.org/practice-management/cpt/cpt-shared-language-health-care.