How to Document CPT Codes in Medical Billing

CPT (Current Procedural Terminology) coding is a process of assigning five digit numerical codes to medical procedures, treatments or services performed by physicians or health care providers. The codes are documented for tracking and billing purposes. CPT codes are then submitted to the health insurer during the medical billing process so that providers can be reimbursed for services provided to patients. CPT codes are updated annually and published by the American Medical Association (AMA).

Things You'll Need

• Patient medical information
• Current CPT coding book (or CPT coding software with current updated codes)
• Medical dictionary

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Instructions

• 1

  Review patient documentation for procedures, treatments and services. Look at physician notes, operative reports and other provider documentation that describe what was performed on the patient.

• 2

  Take notes on the procedures, treatments or services that were performed on the patient. Never write coding notes in the patient’s record. Instead, use a scrap sheet of paper to make coding notes until the codes are assigned.

• 3

  Look up the procedures, treatments or services performed in a CPT code book or on the coding software. Start with the body system or the procedure performed. For example, if a bunionectomy of the toe was performed, the appropriate code(s) can be found in the CPT code book index by looking up “Bunion Repair” or also by looking up “Toe, Repair, Bunion.”

• 4

  Assign the most accurate CPT code to each procedure performed.

• 5

  Review any questions or inconsistencies with the physician or provider. A coder should never guess or interpret information about a procedure that is not documented.

• 6

  List the final CPT code assignments on the appropriate form for billing. Many insurers are now billed electronically, so codes are entered into an electronic form and sent via the Internet to the payer. Be sure to keep a copy of the codes submitted to the payer in the patient’s record for future reference and in case the claim is denied by the insurer.