Medical Coding Tips Using CPT

The American Medical Association developed the Current Procedural Terminology system in 1966 as a standardized coding system for recording patient information and classifying medical data. Hospitals, physician's offices and diagnostic centers use the CPT code book to record information and bill insurance companies. According to Amednews.com, nearly 20 percent of all claims contain errors, costing the health system billions each year. It is very important to properly use CPT codes for accurate billing results.

The Basics

• To properly code medical data, you must have a basic knowledge of anatomy, medical terminology and physiology. To assign the proper CPT code to a diagnosis or procedure, you must be able to identify specific body parts and systems. If you already have a medical background, study health journals, medical dictionaries and anatomy textbooks to refresh your knowledge of the body. Explore online resources that teach anatomy and medical terminology. Make sure all websites and books are endorsed by reputable medical organizations and have up-to-date information. If you don't have a medical background, consider enrolling in an accredited coding program to learn the basics and become certified in medical coding.

Stay Current

• The American Medical Association releases a new CPT coding book every year with updated information for coding professionals. It is very important that coders have the most current CPT book to accurately code medical data. Not using an updated CPT book may result in denials from insurance companies due to new coding changes or the use of discontinued coding numbers. Read the introduction and preface of the newest CPT book to stay current on changes and modifications in the coding system.

Focus

• According to Advance for Health Information Professionals, successful coders must understand the common categories used for CPT coding. Category one contains five-digit numeric codes that comprise the main body of the CPT coding book and is the section health professionals use the most. The codes in category one characterize the most commonly performed procedures and are frequently used by physicians and outpatient providers. Medscape.com reports that 80 percent of physician-related billing uses category one codes and only 25 specific codes are used for 95 percent of everyday billing. For this reason, it is especially important to study and understand the first 30 pages of the CPT manual.

Coding Tools

• Study all paperwork involving patient care to select the most accurate medical codes. Discharge reports and lab sheets provide essential information concerning the patient's level of care. Practice coding directly from the chart to ensure accuracy and avoid common errors. When searching for a code, check the alphabetically arranged index in the CPT manual first. Go directly to the name in the index and quickly locate the correct number. It is also very important to read each subheading, located under the main heading. Subheadings often provide additional information, including more detailed descriptions of the procedures performed.