Accurate medical coding is the backbone of successful healthcare revenue cycle management. With over 10,000 CPT codes and 70,000 ICD-10 codes available, knowing which ones drive the majority of your practice’s billing can make the difference between clean claims and costly denials. This comprehensive reference guide breaks down the most frequently used CPT codes by specialty, paired with common diagnosis codes and essential modifier tips. Whether you’re training new staff or refreshing your coding knowledge, this guide will help streamline your documentation and maximize reimbursement in 2025.
Primary Care CPT Codes & Diagnosis Pairings
Office Visits & Consultations
99213 – Office Visit, Established Patient (Level 3)
- Description: Moderate complexity visit, typically 20-29 minutes
- Common ICD-10: Z00.00 (routine health exam), E78.5 (hyperlipidemia), I10 (hypertension)
- Coding Tips: Document 2 of 3 key components (history, exam, decision-making). Time-based billing requires >50% counseling/coordination.
99214 – Office Visit, Established Patient (Level 4)
- Description: High complexity visit, typically 30-39 minutes
- Common ICD-10: E11.9 (type 2 diabetes), J44.1 (COPD with exacerbation), F32.9 (depression)
- Coding Tips: Requires extensive history, detailed exam, or high-complexity decision-making. Document chronic conditions and medication management.
99215 – Office Visit, Established Patient (Level 5)
- Description: Highest complexity visit, typically 40-54 minutes
- Common ICD-10: N18.6 (ESRD), I50.9 (heart failure), Z51.11 (chemotherapy)
- Coding Tips: Reserve for truly complex cases with extensive documentation. High audit risk – ensure medical necessity is clear.
99203 – Office Visit, New Patient (Level 3)
- Description: Moderate complexity new patient visit, typically 30-44 minutes
- Common ICD-10: Z00.00 (routine exam), M79.3 (panniculitis), R06.02 (shortness of breath)
- Coding Tips: All 3 key components required for new patients. Document chief complaint and comprehensive history.
99204 – Office Visit, New Patient (Level 4)
- Description: High complexity new patient visit, typically 45-59 minutes
- Common ICD-10: E11.9 (diabetes), I25.10 (CAD), F41.9 (anxiety)
- Coding Tips: Comprehensive history and exam required. Document complexity of decision-making and number of diagnoses.
Preventive Care
99395 – Preventive Visit, Age 18-39
- Description: Comprehensive preventive medicine evaluation and management
- Common ICD-10: Z00.00 (routine adult health exam), Z87.891 (personal history of nicotine dependence)
- Coding Tips: Separate from problem-focused visits. Use modifier 25 when billing same-day sick visit.
99396 – Preventive Visit, Age 40-64
- Description: Comprehensive preventive medicine evaluation and management
- Common ICD-10: Z00.00 (routine exam), Z12.31 (screening for cervical cancer), Z13.89 (screening for other disorders)
- Coding Tips: Include appropriate screening codes. Document counseling for risk factors.
99397 – Preventive Visit, Age 65+
- Description: Comprehensive preventive medicine evaluation and management
- Common ICD-10: Z00.00 (routine exam), Z13.850 (screening for cardiovascular disorders), Z87.891 (history of nicotine dependence)
- Coding Tips: Medicare covers annual wellness visits. Consider G0438/G0439 for Medicare patients.
Procedures & Diagnostics
93000 – Electrocardiogram, Complete
- Description: 12-lead ECG with interpretation and report
- Common ICD-10: I25.9 (CAD), I48.91 (atrial fibrillation), R00.2 (palpitations)
- Coding Tips: Includes tracing, interpretation, and report. Don’t bill separately for rhythm strips.
90715 – Tdap Vaccine
- Description: Tetanus, diphtheria, and acellular pertussis vaccine
- Common ICD-10: Z23 (vaccination), S61.9 (wound requiring tetanus prophylaxis)
- Coding Tips: Bill administration code 90471 separately. Check patient vaccine history.
36415 – Venipuncture, Age 3+
- Description: Routine blood draw for laboratory testing
- Common ICD-10: Z00.00 (routine exam), E11.9 (diabetes monitoring), I10 (hypertension)
- Coding Tips: Don’t bill with other procedures involving blood draw. Medicare doesn’t cover routine venipuncture.
71020 – Chest X-ray, 2 Views
- Description: Frontal and lateral chest radiographs
- Common ICD-10: J44.1 (COPD), R05 (cough), Z87.891 (history of smoking)
- Coding Tips: Requires physician interpretation. Use 71010 for single view only.
Physical Therapy CPT Codes & Diagnosis Pairings
Therapeutic Procedures
97110 – Therapeutic Exercise
- Description: Exercises to develop strength, endurance, and flexibility
- Common ICD-10: M25.561 (knee pain), M54.5 (low back pain), S72.001A (hip fracture)
- Coding Tips: Bill in 15-minute units. Document specific exercises and patient response.
97112 – Neuromuscular Re-education
- Description: Training to restore normal movement patterns
- Common ICD-10: G93.1 (brain injury), I69.354 (hemiplegia), M62.81 (muscle weakness)
- Coding Tips: Requires skilled therapy. Document balance, coordination, and proprioception training.
97116 – Gait Training
- Description: Training to improve walking ability and safety
- Common ICD-10: R26.9 (gait abnormality), Z87.891 (history of fall), S72.001A (hip fracture)
- Coding Tips: Bill in 15-minute units. Document assistive devices and safety measures.
97140 – Manual Therapy
- Description: Hands-on mobilization and manipulation techniques
- Common ICD-10: M54.5 (low back pain), M25.511 (shoulder pain), M79.1 (myalgia)
- Coding Tips: Requires direct patient contact. Document specific techniques used.
Modalities
97010 – Hot/Cold Packs
- Description: Application of heat or cold therapy
- Common ICD-10: M25.561 (knee pain), M70.03 (bursitis), M79.3 (panniculitis)
- Coding Tips: Supervised modality. Can’t bill if patient applies independently.
97035 – Ultrasound Therapy
- Description: Therapeutic ultrasound for deep heating
- Common ICD-10: M25.561 (knee pain), M70.03 (bursitis), S83.261A (meniscus tear)
- Coding Tips: Must be applied by therapist or assistant. Document treatment parameters.
97012 – Mechanical Traction
- Description: Motorized traction for spinal decompression
- Common ICD-10: M54.5 (low back pain), M50.20 (cervical disc disorder), M51.26 (lumbar disc displacement)
- Coding Tips: Requires constant attendance. Document patient positioning and weight used.
Evaluations
97161 – PT Evaluation, Low Complexity
- Description: Initial physical therapy evaluation, straightforward case
- Common ICD-10: M25.561 (knee pain), M70.03 (bursitis), S93.401A (ankle sprain)
- Coding Tips: Use for routine musculoskeletal conditions. Document plan of care.
97162 – PT Evaluation, Moderate Complexity
- Description: Initial physical therapy evaluation, moderate complexity
- Common ICD-10: M54.5 (low back pain), M25.511 (shoulder pain), S72.001A (hip fracture)
- Coding Tips: Multiple body regions or comorbidities. Document functional limitations.
97163 – PT Evaluation, High Complexity
- Description: Initial physical therapy evaluation, high complexity
- Common ICD-10: G93.1 (brain injury), I69.354 (hemiplegia), M62.81 (muscle weakness)
- Coding Tips: Complex conditions requiring extensive evaluation. Document barriers to recovery.
Orthopedic CPT Codes & Diagnosis Pairings
Arthroscopic Procedures
29881 – Knee Arthroscopy with Meniscectomy
- Description: Arthroscopic removal of torn meniscus tissue
- Common ICD-10: S83.261A (medial meniscus tear), S83.251A (lateral meniscus tear), M23.201 (derangement of meniscus)
- Coding Tips: Include laterality modifier (LT/RT). Document specific meniscus and extent of tear.
29826 – Shoulder Arthroscopy, Decompression
- Description: Arthroscopic subacromial decompression
- Common ICD-10: M75.30 (shoulder impingement), M75.100 (rotator cuff tear), M25.511 (shoulder pain)
- Coding Tips: Often combined with other shoulder procedures. Use modifier 51 for multiple procedures.
29827 – Shoulder Arthroscopy with Rotator Cuff Repair
- Description: Arthroscopic repair of rotator cuff tear
- Common ICD-10: M75.100 (rotator cuff tear), S46.011A (rotator cuff strain), M75.30 (impingement)
- Coding Tips: Specify partial vs. complete tear. Document repair technique and anchors used.
Joint Replacements
27447 – Total Knee Replacement
- Description: Total knee arthroplasty with or without patella resurfacing
- Common ICD-10: M17.11 (primary osteoarthritis of knee), M17.30 (post-traumatic osteoarthritis), Z96.651 (joint replacement status)
- Coding Tips: Include cement/cementless approach. Document prosthesis type and size.
27130 – Total Hip Replacement
- Description: Total hip arthroplasty with or without cement
- Common ICD-10: M16.11 (primary osteoarthritis of hip), S72.001A (hip fracture), M87.051 (avascular necrosis)
- Coding Tips: Specify approach (posterior, anterior, lateral). Document prosthesis components.
Fracture Care
27766 – Open Treatment of Ankle Fracture
- Description: Open reduction and internal fixation of ankle fracture
- Common ICD-10: S82.851A (trimalleolar fracture), S82.841A (bimalleolar fracture), S82.891A (other ankle fracture)
- Coding Tips: Include laterality modifier. Document hardware used and fracture complexity.
25608 – Open Treatment of Distal Radius Fracture
- Description: Open reduction and internal fixation of wrist fracture
- Common ICD-10: S52.501A (Colles fracture), S52.531A (Smith fracture), S52.511A (Barton fracture)
- Coding Tips: Specify intra-articular vs. extra-articular. Document plate, screws, or external fixation.
Injections
20610 – Arthrocentesis/Injection, Large Joint
- Description: Joint aspiration or injection (knee, shoulder, hip)
- Common ICD-10: M25.40 (joint effusion), M17.11 (knee osteoarthritis), M75.30 (shoulder impingement)
- Coding Tips: Include laterality modifier. Document medication injected and volume aspirated.
20605 – Arthrocentesis/Injection, Intermediate Joint
- Description: Joint aspiration or injection (ankle, wrist, elbow)
- Common ICD-10: M25.40 (joint effusion), M19.021 (osteoarthritis), M70.03 (bursitis)
- Coding Tips: Use appropriate joint size code. Document fluoroscopic guidance if used (77002).
Cardiology CPT Codes & Diagnosis Pairings
Diagnostic Procedures
93307 – Echocardiogram, Complete
- Description: Comprehensive transthoracic echocardiogram with Doppler
- Common ICD-10: I50.9 (heart failure), I25.10 (CAD), I48.91 (atrial fibrillation)
- Coding Tips: Includes 2D, M-mode, and Doppler studies. Don’t bill components separately.
93306 – Echocardiogram, Complete (Real-time with Image Documentation)
- Description: Complete transthoracic echo with real-time imaging
- Common ICD-10: I34.0 (mitral valve insufficiency), I35.0 (aortic stenosis), I42.0 (cardiomyopathy)
- Coding Tips: Requires permanent recording. Document all cardiac chambers and valves.
93000 – Electrocardiogram, Complete
- Description: 12-lead ECG with interpretation and report
- Common ICD-10: I25.9 (CAD), R00.2 (palpitations), I44.2 (AV block)
- Coding Tips: Global service includes tracing, interpretation, and report. Use 93005 for tracing only.
93015 – Cardiovascular Stress Test
- Description: Treadmill or bicycle stress test with ECG monitoring
- Common ICD-10: I25.10 (CAD), Z01.818 (pre-operative exam), R06.02 (shortness of breath)
- Coding Tips: Includes exercise, ECG monitoring, and physician supervision. Document METs achieved.
Interventional Procedures
93458 – Cardiac Catheterization, Left Heart
- Description: Left heart catheterization with coronary angiography
- Common ICD-10: I25.10 (CAD), I20.9 (angina), I21.9 (acute MI)
- Coding Tips: Includes ventriculography when performed. Add 93461 for right heart catheterization.
92928 – Percutaneous Coronary Intervention (PCI)
- Description: Coronary angioplasty with stent placement
- Common ICD-10: I25.10 (CAD), I20.0 (unstable angina), I21.02 (STEMI)
- Coding Tips: Bill per vessel treated. Use add-on codes for additional vessels (92929).
Monitoring
93224 – Holter Monitor, 24-hour
- Description: Continuous ambulatory ECG monitoring for 24 hours
- Common ICD-10: I48.91 (atrial fibrillation), R00.2 (palpitations), I47.1 (supraventricular tachycardia)
- Coding Tips: Includes recording, analysis, and interpretation. Patient must wear for minimum 18 hours.
93226 – Holter Monitor, 48-hour
- Description: Continuous ambulatory ECG monitoring for 48 hours
- Common ICD-10: I48.91 (atrial fibrillation), R00.2 (palpitations), I45.9 (conduction disorder)
- Coding Tips: Use when 24-hour monitoring insufficient. Document medical necessity for extended monitoring.
Gastroenterology CPT Codes & Diagnosis Pairings
Endoscopic Procedures
45378 – Colonoscopy, Diagnostic
- Description: Flexible colonoscopy to cecum or splenic flexure
- Common ICD-10: Z12.11 (screening for colorectal cancer), K63.5 (polyp of colon), K59.00 (constipation)
- Coding Tips: Screening vs. diagnostic affects coverage. Use appropriate screening codes for asymptomatic patients.
45380 – Colonoscopy with Biopsy
- Description: Colonoscopy with biopsy of suspicious lesions
- Common ICD-10: K63.5 (polyp of colon), K51.90 (ulcerative colitis), D12.6 (benign neoplasm)
- Coding Tips: Don’t bill diagnostic colonoscopy separately. Document number and location of biopsies.
45385 – Colonoscopy with Polypectomy
- Description: Colonoscopy with removal of polyps by snare technique
- Common ICD-10: K63.5 (polyp of colon), D12.6 (benign neoplasm), Z87.010 (personal history of colonic polyps)
- Coding Tips: Use regardless of polyp size. Document polyp location and removal technique.
43239 – Upper Endoscopy, Diagnostic
- Description: Esophagogastroduodenoscopy (EGD) for diagnostic purposes
- Common ICD-10: K21.9 (GERD), K25.9 (gastric ulcer), R10.13 (epigastric pain)
- Coding Tips: Examine esophagus, stomach, and duodenum. Document findings and photo documentation.
43249 – Upper Endoscopy with Biopsy
- Description: EGD with tissue biopsy for histological examination
- Common ICD-10: K25.9 (gastric ulcer), K29.70 (gastritis), D13.1 (gastric neoplasm)
- Coding Tips: Document biopsy sites and number of specimens. Don’t bill diagnostic EGD separately.
Liver Procedures
47000 – Liver Biopsy, Needle
- Description: Percutaneous liver biopsy with needle
- Common ICD-10: K72.90 (hepatic failure), K76.0 (fatty liver), B18.2 (chronic hepatitis C)
- Coding Tips: May require imaging guidance (76942). Document biopsy approach and complications.
43204 – Esophageal Varices Ligation
- Description: Endoscopic ligation of esophageal varices
- Common ICD-10: I85.00 (esophageal varices), K92.2 (GI bleeding), K70.30 (alcoholic cirrhosis)
- Coding Tips: Emergency vs. elective affects coding. Document number of bands placed.
Dermatology CPT Codes & Diagnosis Pairings
Skin Lesion Procedures
11401 – Excision of Benign Lesion, 0.6-1.0 cm
- Description: Excision of benign skin lesion with simple closure
- Common ICD-10: D23.9 (benign skin neoplasm), L72.9 (epidermal cyst), I78.1 (nevus)
- Coding Tips: Measure largest diameter. Include margins in measurement. Document pathology results.
11402 – Excision of Benign Lesion, 1.1-2.0 cm
- Description: Excision of benign skin lesion with simple closure
- Common ICD-10: D23.9 (benign skin neoplasm), L72.9 (epidermal cyst), L57.0 (actinic keratosis)
- Coding Tips: Use appropriate size code. Document anatomical location affects coding level.
11600 – Excision of Malignant Lesion, 0.5 cm or less
- Description: Excision of malignant skin lesion with margins
- Common ICD-10: C44.92 (basal cell carcinoma), C43.9 (malignant melanoma), C44.99 (squamous cell carcinoma)
- Coding Tips: Measure lesion plus margins. Document pathology confirmation of malignancy.
17000 – Destruction of Benign/Premalignant Lesion
- Description: Destruction of single lesion by any method
- Common ICD-10: L57.0 (actinic keratosis), L82.1 (seborrheic keratosis), B07.9 (viral wart)
- Coding Tips: First lesion only. Use 17003 for additional lesions (2-14). Document destruction method.
Biopsies
11102 – Tangential Skin Biopsy
- Description: Shave biopsy of skin lesion
- Common ICD-10: D48.5 (uncertain behavior neoplasm), L98.9 (skin lesion), C44.92 (basal cell carcinoma)
- Coding Tips: Single lesion code. Use 11103 for each additional lesion. Document specimen size.
11104 – Punch Skin Biopsy
- Description: Punch biopsy of skin lesion
- Common ICD-10: D48.5 (uncertain behavior neoplasm), L40.9 (psoriasis), L30.9 (dermatitis)
- Coding Tips: Single lesion code. Use 11105 for additional lesions. Document punch size used.
Mohs Surgery
17311 – Mohs Surgery, First Stage
- Description: Mohs micrographic surgery, first stage
- Common ICD-10: C44.92 (basal cell carcinoma), C44.99 (squamous cell carcinoma), C43.9 (melanoma)
- Coding Tips: Includes excision and microscopic examination. Use 17312 for additional stages.
17313 – Mohs Surgery, Additional Stage
- Description: Each additional stage of Mohs surgery
- Common ICD-10: C44.92 (basal cell carcinoma), C44.99 (squamous cell carcinoma)
- Coding Tips: Add-on code for each stage beyond the first. Document clear margins achieved.
Coding Best Practices for 2025
Understanding these high-volume codes is just the beginning. Successful medical coding requires attention to documentation, staying current with annual updates, and implementing systematic quality checks. Consider conducting regular coding audits to identify patterns in denials and ensure your team is maximizing reimbursement opportunities.
For practices looking to optimize their coding accuracy and reduce claim denials, professional billing audits can identify specific areas for improvement. Additionally, staying informed about modifier usage and bundling rules will help prevent costly coding errors that impact your bottom line.
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