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How to Read Your Medical Bill

Understanding CPT codes can help you avoid inaccurate charges

A Current Procedural Terminology (CPT) code is the five-numbered code you will find in parenthesis on your Medicare Summary Notice (MSN) , insurance's Explanation of Benefits (EOB), and doctor and hospital statements. This billing code represents the medical service or services you received from your health care provider.

These codes are created, maintained and copyrighted by the American Medical Association (AMA). There are thousands of different CPT codes, which the AMA's editorial boards review and update each year.

Why are CPT codes important?

•They provide uniformity and help simplify the health care claims process. Specific words and numbers refer to and describe specific medical procedures and services.

For example, if your doctor's visit included a physical and a flu shot, you would receive a summary of your office visit and be given a form containing a list of possible services. The services you received should be circled, i.e., "99214" for the physical examination and "90658" for the flu shot.

•They determine the amount of reimbursement your health care provider will receive from your insurance company. The amount a provider receives for a specific code can vary depending on the insurance company. The codes also determine how much you may need to pay out-of-pocket through co-payments or coinsurance.

If you have Medicare, every provider in your geographic region receives the same amount for a specific code. Medicare uses a Healthcare Common Procedure Coding System (HCPCS), which is based on the CPT codes. The Level I codes of the HCPCS are identical to the CPT codes. The Level II codes of the HCPCS are used by medical suppliers such as ambulance services or durable medical equipment companies.

How to use CPT codes

You can use them to:

•Track your claims through the payment system.

•Review medical billings from practitioners, laboratories, hospitals or any other health care provider, as well as statements from your insurance company or Medicare.

Tracking and reviewing your claims helps you ensure that you and your insurer pay only for services you actually received.

Before you leave your doctor's office

Obtain a summary of your appointment that details the services you received and their associated CPT codes. You have a right to this information. If you don't see the codes, request a new statement that includes them.

When you get your EOB or MSN

•Verify that the CPT codes on your doctor's statement match the codes on your insurance statement. If you don't see the codes, request a new one.
•If the codes from the provider or insurance company don't match, or if the codes appear for services that you didn't receive, contact your provider and insurance company.
•If you are on Medicare, call 800-MEDICARE (800-633-4227). The phone number is on the front of your MSN.number is on the front of your MSN.
•Use our Medicare Summary Notice Decoder to help you understand all the information on your summary notice.

For more information on CPT codes, visit the AMA website. This site is only for consumers and limits your search to five codes or keywords. You can also ask your doctor or your insurance company for information about CPT codes.

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