Guidelines for Internal Medicine CPT Codes (PDF)

Adult disease prevention, diagnosis, and treatment are the main goals of internal medicine. It treats several conditions involving the heart, lungs, gastrointestinal tract, liver, and kidneys.

Internists are trained to identify and treat complicated medical conditions utilizing clinical expertise, laboratory tests, and imaging. They take care of patients’ primary health needs and, if necessary, coordinate care with other experts. Internal medicine aims to treat the whole person, not simply the symptoms they may be experiencing.

It is a crucial area of study in healthcare since it ensures patients get the greatest treatment and care possible. Let’s look at the standard CPT codes used in internal medicine and the descriptions of those codes.

Guidelines for Internal Medicine CPT Codes

Internal Medicine CPT Codes

• Visit an outpatient clinic or office – 99213: This code describes a simple office visit for an established patient. This entails minimal procedural time, a concise physical examination, and straightforward medical decisions.
• Visit an outpatient clinic or office – 99214: This code reports a moderately complex office visit for an established patient. This includes a detailed background and physical exam, making moderately complicated medical decisions, and discussing how to deal with or treat the patient.
• Initial hospitalization – 99223: This code documents the assessment and treatment of newly admitted hospital patients. This entails taking a thorough medical history and examination, making difficult medical decisions, and coordinating care with other medical specialists.
• Following hospital treatment – 99233: This code records a patient’s additional hospital visits after their first admission. This entails taking a thorough medical history and examination, making difficult medical decisions, and coordinating care with other medical specialists.
• ECG – Electrocardiogram – 93000: This code reports the results and interpretation of an ECG, which monitors the heart’s electrical activity.
• X-ray of the Chest –71020: This code reports the results and interpretation of a chest X-ray, which employs electromagnetic waves to make images of the chest and its contents.
• CBC, or a complete blood count – 85025: This code indicates the results and interpretation of a CBC, a blood test that evaluates several parts of the blood, for example, red blood cells, white blood cells, and platelets.
• Urine testing – 81000: This code documents the results of a urinalysis, which looks for proteins, sugars, and germs in the urine.
• Administration of immunizations – 90460-90461, 90471-90474: The administration of vaccinations to patients is reported using these codes. The code used varies depending on how many vaccines were given and what kind of advice was given to the patient.
• Examination of pulmonary function –94010: A pulmonary function test is a diagnostic process used to evaluate respiratory health, and its results are reported using this code.
• Performing an Echocardiogram — 93306: The echocardiogram is a test that employs sound waves to make images of the heart, and this code is used to describe its results and analysis.
• The colonoscopy – 45378: Colonoscopy is a diagnostic process that looks for problems in the colon, and this code is used to record its execution and results.
• Flexi-sigmoidoscopy – 45330: This code documents the execution and analysis of flexible sigmoidoscopy, a test that looks for lower colon and rectum anomalies.
• Consultation on E/M – 99241-99245: Medical specialists and other medical professionals are consulted using these codes for second opinions and treatment plans.
• Hemodialysis – 90935-90999: Hemodialysis services, which include drawing blood, filtering it, and returning it to the patient, are reported using these codes.
• Administering chemotherapy –96401-96549: Patients’ receipt of chemotherapy medications by infusion, injection, or mouth is reported using these codes.
• CT imaging –74177: This code reports the outcomes and conclusions of a computed tomography (CT) scan, a diagnostic imaging technology that employs X-rays to generate comprehensive pictures of the body.
• MRI—Magnetic resonance imaging – 72141: This code describes the results and interpretation of an MRI. This diagnostic imaging method uses a robust magnetic field and radio waves to create detailed body images.
• Sleep analysis – 95806-95811: Sleep studies analyze a patient’s sleeping habits and diagnose sleep problems; these codes report the study’s execution and evaluation.
• Catheterization of the heart – 93458: This code reports the outcome and understanding of cardiac catheterization, a medical procedure that inserts a catheter into the heart to identify and cure certain conditions.
• EEG – Electroencephalogram – 95819: This code reports the results and interpretation of an EEG, a diagnostic procedure that monitors brain electrical activity.
• EMG – Electromyography – 95885: A diagnostic test, an EMG, measures electrical activity in muscles and nerves, and this code is used to report its administration and results.
• The endoscope – 43235-43259: These codes document endoscopic procedures, which look inside the digestive tract using a tiny, flexible tube equipped with a camera and light.
• The carotid ultrasound – 93880: Carotid ultrasonography, a non-invasive diagnostic procedure that uses sound waves to generate pictures of the coronary arteries in the neck, is reported using this code.
• Intermittent treatment – 96365-96379: These codes document the intravenous (IV) line delivery of fluids, medicines, or other substances.
• Treating wounds – 97597-97606: These codes should be utilized when documenting wound care, such as cleaning, debridement, and dressing changes.
• Long-term services – 99354-99357: These codes report face-to-face services that last longer than a regular office visit, like a patient being evaluated and cared for a more extended period.
• Allergy testing –95004-95078: These codes reflect skin and blood allergy tests to identify allergens that may be causing a patient’s allergic responses.
• Bone density scan – 77080: This code reports the results and interpretation of a DEXA bone density scan, which evaluates bone mineral density to detect osteoporosis and fracture risk.
• Holter monitoring – 93224: This code reports the supply and interpretation of ambulatory electrocardiographic recording, also known as a Holter monitor, which records the heart’s electrical functionality for 24 to 48 hours to examine irregular heart rhythms.
• Vaccinations – 90471-90749: These codes indicate patient vaccinations, including routine, influenza and additional immunizations.
• Arterial blood gas (ABG) analysis – 82803: This code reports arterial blood sample analysis for oxygen, carbon dioxide, and other parameters to determine a patient’s respiratory and metabolic condition.
• Nerve conduction study – 95904: A nerve conduction study analyzes the speed and intensity of electrical signals along nerves to assess nerve function and discover problems. This code reports its performance and interpretation.
• Colonoscopy with polypectomy – 45385: This code reports the execution and interpretation of a colonoscopy that removes polyps or anomalous growths in the colon or rectum.
• Excision of skin lesion – 11400-11646: These codes reflect the excision of skin lesions such as moles, cysts, and tumors utilizing different surgical procedures and sizes.

Also read: CPT codes for Radiology Procedures

• Thoracentesis – 32554: This code reports the placement of a needle into the pleural space (into the lungs and chest wall) to remove fluid or air for diagnostic or therapeutic purposes.
• Lumbar puncture – 62270: This code reports the insertion of a needle into the lower back, and spinal canal to collect cerebrospinal fluid (CSF) for diagnostic or therapeutic purposes.
• Pulmonary rehabilitation – 94620-94621: Pulmonary rehabilitation services—exercise, breathing exercises, education, and counseling to enhance lung function and respiratory health—are reported using these codes.
• Continuous positive airway pressure (CPAP) management – 94660: This code documents the start and maintenance of CPAP therapy, which uses a machine that delivers constant air pressure to clear your airways while you sleep.
• Evaluation and management of chronic conditions – 99487-99489: These codes describe comprehensive chronic care management services that analyze, monitor, and coordinate treatment to enhance patient outcomes.
• Transesophageal echocardiography (TEE) – 93312: TEEs, which require putting a probe into the esophagus to take detailed pictures of the heart, are reported using this code.
• Excisional biopsy – 11100-11101: These codes reflect the surgical removal of tissue or lesion for diagnosis.
• Transcutaneous electrical nerve stimulation (TENS) – 64550: TENS treatment uses low-voltage electrical currents to reduce pain and speed recovery.
• Exercise stress test – 93015: This code reports the results and interpretation of an exercise stress test, a diagnostic procedure that measures the heart’s reaction to exercise and checks for cardiovascular problems.
• Joint injection – 20600-20611: These codes are used to report the injection of medication into a joint to alleviate pain, reduce inflammation, or improve joint mobility. Different codes are used depending on the specific joint and the injection technique.
• Pulmonary function testing with diffusion capacity – 94729: This code describes a pulmonary function test that measures diffusion capacity, which measures how well oxygen is transported from the lungs to the circulation.
• Ankle-brachial index (ABI) – 93922: The ankle-brachial index, a non-invasive test that compares ankle and arm blood pressure to diagnose peripheral artery disease, is measured and interpreted using this code.
• Genetic testing – 81400-81408: These codes are used to report various types of genetic tests, including molecular analysis and DNA sequencing, to identify genetic mutations, assess disease risk, or guide treatment decisions.
• Medication management – 99356: This code reports complex medication management services, which involve assessing and optimizing a patient’s medication regimen, monitoring drug interactions or side effects, and providing education and counseling.
• Telehealth visits – 99201-99215 (with the appropriate telehealth modifier): These codes are used to report the provision of evaluation and management services through telecommunication technology, allowing healthcare professionals to assess and treat patients remotely.
• Ambulatory blood pressure monitoring – 93784: Ambulatory blood pressure monitoring involves wearing a portable device that takes blood pressure at regular gaps over 24 hours to examine blood pressure trends. This code reports its provisions and interpretation.
• Prothrombin time (PT) and International Normalized Ratio (INR) – 85610: PT/INR – 85610: This code reports blood clotting and anticoagulant drug PT and INR readings and interpretation.
• Intensive care unit (ICU) services – 99291-99292: These codes record ICU critical care services, including patient evaluation, treatment, and monitoring.
• Transfusion services – 36430-36479: The collection, processing, and administration of blood or blood products to patients are reported using these codes.
• Incision and drainage – 10060-10180: These codes are used to report the surgical incision and drainage of abscesses, cysts, or other fluid collections, which involves opening the area to allow the contents to drain and promote healing.
• Continuous glucose monitoring (CGM) – 95249-95251: These codes are used to report the provision and interpretation of continuous glucose monitoring, which involves wearing a device that measures and records glucose levels throughout the day to manage diabetes.
• Nerve block – 64400-64450: These codes are used to report the injection of an anesthetic or medication near a particular nerve or group of nerves to block pain signals and provide temporary pain relief.
• Ambulatory electrocardiographic monitoring – 93225: This code reports the provision and interpretation of ambulatory electrocardiographic monitoring, such as a Holter monitor or event monitor, to evaluate and diagnose heart rhythm abnormalities.
• Removal of foreign body – 10120-10180: These codes are used to report the removal of foreign bodies from various body areas, including skin, ears, nose, and soft tissues.

Also read: CPT Codes for Hematology

Conclusion

Correct coding and paperwork are necessary to ensure that medical services are billed and paid for correctly. Although there are many CPT codes for internal medicine, the ones mentioned above serve as the cornerstone for efficient billing, particularly for the services that are reimbursed the most frequently.  It’s important to stay up-to-date on coding improvements and best practices if you want your documentation and coding to be effective. By carefully coding and documentation, medical providers may ensure proper compensation while delivering high-quality patient care.