Common Billing Terminology:

CPT Codes:

Stands for current procedural terminology that are 5 digit numeric or alpha-numeric codes developed by the American Medical Associatopm (AMA) to standardize the reporting of medical, surgical, radiology, laboratory, and evaluation/management services. They act as a universal language for healthcare, allowing providers to communicate specific procedures to payers for reimbursement.

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CPT II Codes:

CPT Category II codes are supplemental tracking codes that can be used for performance measurement. The use of the tracking codes for performance measurement will decrease the need for record abstraction and chart review and thereby minimize administrative burdens on physicians and other health care professionals.

These codes are intended to facilitate data collection about quality of care by coding certain services and/or test results that support performance measures and that have been agreed upon as contributing to good patient care. Some codes in this category may relate to compliance by the health care professional with state or federal law.

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HCC:

Stands for Hierarchical Condition Categories, a risk-adjustment model used by Centers for Medicare & Medicaid Services (CMS) to calculate payments for Medicare Advantage plans and other value-based programs. It groups ICD-10 diagnosis codes into categories that predict a patient’s expected health costs and complexity. Higher, accurately coded HCCs lead to higher reimbursements for complex patients.

• Risk Adjustment Factor (RAF) Score: HCC codes determine a patient’s RAF score, which reflects the severity of their chronic conditions.
• Purpose: Ensures providers are properly compensated for managing complex, chronic patients.
• Documentation: Requires accurate, annual documentation of all chronic conditions (e.g., diabetes, COPD) to justify the payment model.
• Impact: Poor documentation results in lower risk scores and lower payments.

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ICD-10-CM/PCS:  

Stands for standardized coding system used in healthcare to classify diseases, injuries, and inpatient procedures. These codes are alphanumeric and range from 3–7 characters, allowing providers and billers to accurately document conditions and procedures for healthcare billing, reporting, and data analysis.

If your practice/billers have any questions regarding any coding questions, please contact Marisa Dobek, Risk Coding Specialist at mdobek@opns.org; p:248-682-0088 Ext 125

This page is intended for educational use only. The following resources have been created by OPNS, and information has been verified through payor standards. Please see below for our various topics of the latest billing and coding guidelines.

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