HCPCS and CPT Codes: Do You Know the Differences?

by  Find-A-Code™
Oct 4th, 2023

Two of the most commonly used coding systems in medical billing are the HCPCS and CPT codes medical billers and coders are intimately familiar with. They share some similarities, but they are by no means identical. Do you know the differences between the two coding sets?

It is important not only to know where and how to find the correct HCPCS and CPT codes, but also to know why the two code sets are used. They differ in both structure and scope. As far as the latter is concerned, one's purpose for applying a code will partially influence the choice of either the HCPCS or CPT code.

HCPCS and CMS

The HCPCS (Healthcare Common Procedure Coding System) is a system developed by the Centers for Medicare and Medicaid Services (CMS) to report medical procedures and services offered to subscribers of the two government health insurance plans. Any healthcare provider who bills either Medicaid or Medicare makes generous use of HCPCS codes.

The codes are categorized as either Level I or Level II. Level I codes are identical to CPT codes. Coders and billers utilize them to report procedures and services provided by licensed clinicians.

Level II codes are not for services or procedures. Rather, they are utilized to bill for products, supplies, and non-clinician services that are not covered under the CPT code set. Think prosthetics and mobility devices, as examples.

CPT and the AMA

Where HCPCS codes were developed by CMS, CPT (Current Procedural Terminology) codes were developed by the American Medical Association (AMA) decades ago. The AMA continues to own and maintain the code set.

CPT codes are the primary means through which healthcare providers bill for their clinical services and procedures. As such, the CPT code set is the largest among the many code sets that medical billers and coders have to work with. The AMA routinely reviews its code set and makes modifications as necessary.

Every change to the code set is released well in advance of its official adoption. This gives billers and coders ample time to familiarize themselves with the changes before they have to start implementing them.

Codes for Billing and Documentation

Perhaps the biggest difference between HCPCS and CPT codes is their scope. The former are reserved entirely for procedures and services built to Medicare and Medicaid. Meanwhile, the CPT code set has a much broader scope in that it covers all sorts of private insurance companies and self-funded health plans. Both sets are designed to make billing and documentation easier.

From a billing standpoint, medical codes present payers with detailed information on what they are paying for without requiring a full review of the notes and records associated with each bill. Consider the codes as a form of medical shorthand.

In terms of documentation, medical codes serve a similar purpose but with a different outcome. Imagine the notes a clinician would take during a typical patient visit. Notes can get rather lengthy based on the level of detail the clinician wants to include. But much of what the clinician records can be condensed with medical codes.

Both Sets Have the Same Goal

Although the HCPCS and CPT code sets differ in terms of structure and scope, the two sets have the same end goal: more accurate documentation and medical billing. Despite the fact that medical coding and billing are complicated, think how much more complicated they would be without code sets.

Medical coders and billers are very familiar with the HCPCS and CPT code sets. They need to be. Their livelihood depends on understanding the codes and how to use them.