Billing Code Systems

Standardized code sets like CPT (Current Procedural Terminology) and ICD (International Classification of Diseases) are essential for documentation, billing, and analytics. CPT Codes: AMA’s Proprietary Model The American Medical Association (AMA) created and maintains the CPT code set, which is used primarily for outpatient and ambulatory procedures. • Business Model: The AMA licenses CPT codes to orgs that need access, such as healthcare providers, insurers, and EHR vendors. Fees are typically based on usage, and larger orgs pay significantly for enterprise-wide licenses. • Distribution: The AMA partners with various orgs, like healthcare IT firms and EHR providers, who incorporate CPT codes into their software. These partners, in turn, pass the costs along to their customers through licensing fees or subscriptions. • Reach: CPT codes are sold and resold through various channels. For example, an EHR vendor licensing CPT codes from the AMA may bundle these into a software package, which is then sold to healthcare providers. ICD Codes: WHO’s Public Domain Approach ICD codes follow a different model. The WHO develops these codes, which are updated and adapted by national bodies. In the U.S., the NCHS, a part of the CDC, is responsible for ICD-10-CM (for clinical modification) and CMS manages ICD-10-PCS (for procedure coding). • Business Model: Unlike CPT, ICD codes are considered public domain globally. However, some value-added services—like training, consulting, and integration—generate revenue for orgs involved in ICD implementation and use. • Distribution: Because ICD codes are publicly available, various orgs, including software vendors, consultants, and academic institutions, distribute them. These orgs might charge for ancillary services, like code training, consulting, or integration with other IT systems. • Reach: ICD codes are integrated into HIT systems without direct licensing fees to end users. However, orgs often provide these codes within software packages or charge for enhanced functionality that supports ICD code use, like advanced analytics or billing modules. Comparing the Two Models • Revenue: CPT codes provide a direct revenue stream for the AMA, which funds further advocacy and policy initiatives. ICD codes, however, generate revenue for third-party companies offering value-added services, rather than directly benefiting the WHO. • Distribution: Both CPT and ICD codes rely on intermediaries like EHR vendors, but while CPT licenses are bundled into software products, ICD codes are freely integrated, with costs often tied to value-added services rather than the codes themselves. • Impact on End Users: The proprietary nature of CPT codes can lead to higher costs for end users, as licensing fees trickle down from EHR vendors to healthcare providers. ICD codes, being public domain, do not have licensing fees but can still contribute to costs through the added services needed to implement them effectively.

In 2025, updated CPT codes went into effect to better reflect the post-pandemic clinical landscape and support digital innovations in healthcare. One of the largest changes is the introduction of new (98000–98016) for telehealth Evaluation & Management (E/M). Previously, telehealth E/M would be coded with 9920X/9921X, and the new codes are a reflection of their in-person equivalents. Why make this change? ↳ Clarity: better differentiation between in-person and virtual services, which previously would have been indicated in the note (and with modifier 95) ↳ Flexibility: explicitly allowing for audio-only sessions when required ↳ Parity: better protection for reimbursement of virtual services Given the scope of this change, I am surprised I haven’t heard more about it. Payers also seem to be unclear on what to make of the updates: ↳ Medicare has specifically rejected the new codes. ↳ Other payers are divided on their acceptance of new codes, old codes, or both. ↳ Clinicians have reported delays in reimbursement due to these changes. The APA is providing ongoing recommendations, last updated in May: ↳ For Medicare, continue using old E/M codes, modifiers, and place-of-service ↳ For all other payers, periodically check with each payer ↳ Send concerns about denials to practicemanagement@psych.org Other considerations: ↳ Educate your team about the new codes, including inconsistencies ↳ Ensure your billing system is equipped to handle the new codes ↳ Update note templates. Telehealth E/M codes require documentation of time thresholds, modality (audio-video vs audio only, secure platform), and patient consent for telehealth. Bottom line:  ↳ While the new CPT 98000-series may bring greater clarity and parity with in‑office care, payers are inconsistent with recognition of these codes.  ↳ For now, these changes introduce additional administrative burden including verification of individual payer policies and adapting existing coding/documentation workflows.  ↳ Expect this patchwork system to exist for some time. --------------------- ⁉️ Are you using the new codes in your practice? Did I get anything wrong? Have I been living under a rock? 🔄 Share this post to help clinicians stay current with billing and compliance standards. ✅ Follow me for more on psychiatry, translational neuroscience, and medical informatics.

January 1, 2026 changed everything for PT practice RTM billing. Two new CPT codes were approved in the CMS Final Rule. 98985: Captures 2-15 days of data (National Avg Reimbursement = $40.08) 98979: Captures 10-19 minutes of treatment management (National Avg Reimbursement = $26.39) Why this matters: OLD rules required 16+ days of data and 20+ minutes of provider time. That excluded: - Short-term post-op patients (discharged before hitting 16 days) - Lower-intensity monitoring (quick weekly check-ins) - Patients who need support but not full 20-minute management NEW rules let you bill for patients you were previously leaving on the table. Real scenario: Post-op TKR patient, Week 3: - PT does 15-minute check-in call - Reviews HEP and symptom data from past 7 days (4 days total data) - Adjusts HEP based on adherence trends and current functional status Under 2025 rules: $0 billable (didn't hit 16 days or 20 minutes) Under 2026 rules: $66.47 billable (98985 + 98979) Multiply that across your post-op caseload. That's not "nice to have" revenue. It's material. And that's not even including 98975 ($21.71 on avg) billed once per episode or higher levels of engagement! The practices that quickly adopt these codes will capture this. The practices that don't will leave it on the table. Are you tracking the 2026 RTM changes? Or are you waiting to see what happens?

Attention Audiologists: 12 New Hearing Aid Service Codes go into Effect and six Current Hearing Aid Service Codes (92590-92595) will be Deleted on January 1, 2026. Despite information being presented by some, these codes can significantly affect some providers. I have outlined who will be affected and why may not be affected below. What providers could these code changes impact the most: - The in-network provider who offers and/or bills an unbundled or itemized hearing aid delivery. - In-network providers of health plans, payers and insurers who recognized 92590-92595 and/or who recognized hearing aid services represented by 92700 (unlisted otorhinolaryngological procedure or service) or V5299 (hearing service, miscellaneous) as non-covered.  This could include, but is not limited to: 1) Commercial health plans and insurers, specifically Blue Cross Blue Shield Association and Aetna health plans.  2) State Medicaid programs. 21 State Medicaid programs ONLY recognize the six deleted codes (and not also the V codes) for hearing aid services. 3) State Early Periodic Screening, Diagnosis and Treatment (EPSDT) programs. 4) State Vocational Rehabilitation programs. 5) State and federal Worker’s Compensation programs.  6) VA Community Care. What providers could these code changes impact the least: - The provider, whether offering a bundled, unbundled, or itemized delivery, who is out of network for every health plan, payer, and insurer except for traditional Medicare (may see little or no impact). - The provider who never utilized 92590-92595 and/or never provided services represented by 92700.  Please note that, if this has been your process, there are billing situations where you may have left revenues on the table.   These providers only use HCPCS V-codes (such as V5010, V5011, and/or V5020) to represent and bill for hearing aid related services.  Please note that, if this has been your process, there are billing situations where you may have left revenues on the table.  It is uncertain if or how these code changes will impact hearing benefit/care plan or third-party administrator professional fees and billing policies and allowances. Please know that, if meaningful, practical resources are not being offered by your national association, there are resources available through the Academy of Doctors of Audiology (ADA) for its members and through my company, Audiology Resources. It will be addressed in my upcoming training events.

Inpatient medical coding is the specialized process of translating a formally admitted hospital patient's diagnoses and procedures into standardized codes for billing and data reporting. It requires analyzing complex medical records to assign ICD-10-CM (diagnoses) and ICD-10-PCS (procedures) codes to secure reimbursement. Understanding the mechanics, standards, and workflow of inpatient coding involves the following essential components: Code Sets Used Unlike outpatient coding, which heavily relies on CPT codes for procedures, inpatient facility coding uses entirely different systems. Diagnoses (ICD-10-CM): Used to capture all conditions evaluated, treated, and impacting the length of stay or resources required. Procedures (ICD-10-PCS): An exclusively inpatient system consisting of 7-character alphanumeric codes that describe procedures with immense detail (e.g., approach, device, and body part). Reimbursement: MS-DRG System Inpatient claims are reimbursed through Medicare Severity Diagnosis-Related Groups (MS-DRGs) rather than individual line-item fees. MS-DRGs bundle services based on: The Principal Diagnosis (the condition established after study to be chiefly responsible for the admission). Significant Secondary Diagnoses. Complications and Comorbidities (CCs) or Major Complications and Comorbidities (MCCs), which significantly increase the payment weight of the DRG. Procedures performed. The Coding Workflow Coders do not just pick codes; they review entire hospital stays, following the Official ICD-10-CM/PCS Guidelines for Coding and Reporting: Record Review: Coders typically start by examining the discharge summary and History & Physical (H&P) to grasp the full scope of the admission. Reporting Criteria: Secondary diagnoses are only coded if they require clinical evaluation, therapeutic treatment, extend the length of stay, or increase nursing care Provider Queries: If clinical documentation is ambiguous, conflicting, or incomplete, the coder must submit a query to the attending physician for clarification prior to final code assignment. #codingclarified #cpc #medicalcoding #aapceducationpartner