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Medical Coding Made Easy

Medical coding is the process that assigns specific codes to procedures and diagnoses performed by medical professionals. These codes allow for reimbursement for services provided from insurance companies and other agencies.

  1. CPT coding book

    • Medical coding assists in the identification of claims and displays a history of services performed on patients. Coders convert notes from physicians into codes that are transmitted to insurance providers in return for compensation for services rendered. One important tool is needed to correctly code a procedure--a CPT coding book for the current year. There are various sites available on the Internet that offer an electronic version of the book.

    Six Main Sections

    • There are six main sections of CPT codes and descriptors. These are the E/M Service, Anesthesia, Surgery, Radiology, Pathology & Laboratory, and Medicine. There are also 13 appendices and an alphabetical index. The appendices are as follows:

      Appendix A: Modifiers
      Appendix B: Summary of Additions, Deletions, and Revisions
      Appendix C: Clinical Examples
      Appendix D: Summary of CPT Add-on Codes
      Appendix E: Summary of CPT Codes Exempt from Modifier -51
      Appendix F: Summary of CPT Codes Exempt from Modifier -63
      Appendix G: Summary of CPT Codes That Include Moderate (Conscious) Sedation
      Appendix H: Alphabetic Index of Performance Measures by Clinical Condition or Topic
      Appendix I: Genetic Testing Code Modifiers
      Appendix J: Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves
      Appendix K: Product Pending FDA Approval
      Appendix L: Vascular Families
      Appendix M:: Crosswalk to Deleted CPT Codes

    Alphabetical Index

    • When using the Alphabetical Index to locate CPT codes, always perform the search in the following manner:
      1. Look for the procedure or service performed
      2. Look for the organ or anatomic site that is involved
      3. Look for the condition that is being treated
      4. Look for synonyms, synonyms or abbreviations used

    Understanding How the Entries Are Made

    • An important step in the process of medical coding is the understanding of how the entries to the index have been made. Entries generally fall into one or more of the following categories:

      Main Terms
      Modifying Terms

      Main Terms and Modifying Terms will be divided further into the following sections:
      Main Terms
      1. By Procedure or Service
      2. By Organ
      3. By Condition
      4. By synonyms, eponyms and abbreviations
      Modifying Terms
      1. Cross References
      A. See
      B. See Also

    Documentation

    • The process of Medical Coding requires the coder to have the proper medical record support for the procedures, services and supplies that are billed. In the case of an audit done by Medicare or any other private carrier, improper documentation could result in high fines, loss of practice, court charges brought against the medical professional and more. Always check and double check when coding before you submit the file for payment.

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