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Expert Tips on Coding With CPT

Current Procedural Terminology (CPT) is a book of codes produced by the American Medical Association (AMA). Hospitals and private physicians used the CPT to report and then bill performed procedures. A coder and/or billing professional is trained to read and find the code that best fits the procedure so that proper payment can be received by the insurance company.

  1. The First 30 Pages

    • The first few pages of the CPT book are give you coding guidelines to follow. Included in the pages are the evaluation and management services (E/M). For a private physician this documents a good portion of his services. Although the same codes are used often to document these services it is still a good idea to keep abreast of any changes that may occur as the CPT book is updated every year.

    Code By The Noun

    • Another book used alongside the CPT is the ICD-9 book. This book list all diseases. The ICD-9 codes must be present to support the CPT codes or else the insurance claim may be rejected. Sometimes it helps to find the ICD-9 code first as it may give more information to help find the procedures that normally are performed with that disease.

    Index

    • The index is listed alphabetically. When the doctor lists the procedures performed, go directly to the name in the index to find the page where it's listed in the book.

    Subheadings

    • To determine the correct code, it's critical to read each subheading under the main procedure heading. Each subheading lists specific and more detailed information that pertains to a particular aspect of a procedure.

    Read The Chart

    • Coding directly from the chart can ensure accuracy. The discharge summary and opt reports details exactly what was done to the patient. These two documents, along with the lab report, will give a complete picture of care provided so the coder can select the best CPT code.

    Cheat Sheet

    • As a Coder you will use the same codes often, especially if you are coding for a particular practice. Once you have found a code add it to your cheat sheet to save time when you need that code again. Note: This doesn't preclude you from referring to the CPT book. It allows you to look up the code faster, but you still need to review the code to ensure it is the correct code for the particular case.

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