Ashworth college medical coding

USING THE CPT TO CODE FOR PROCEDURES AND SERVICES

When the doctor sees a patient in the office, he or she checks off all the services and procedures performed during that visit, in addition to the diagnoses for that visit. Sometimes the nurse or medical assistant will assist in checking off the procedures.

CPT codes are usually marked on the encounter form or routing slip, but other services might be handwritten. Codes are then added to the claim form, and they must be consistent with the diagnosis from the patient visit. By the time this encounter form gets to you, the patient will be long gone, and you’ll have to decipher the checks and marks the physician made on this form. If you aren’t receiving clear and complete information, you must communicate this with the office manager or physician to remedy the situation. With the federal government increasingly rooting out fraud and abuse, proper CPT coding and billing can decrease your chances for a Medicare audit and will help avoid the recoding of your services by insurers.

The process of coding procedures is accomplished by finding the correct description of the procedure in Level I of the HCPCS system. The Level II codes are applied to the supplies, medications, therapeutic substances, medical equipment, and certain specialized services needed by the patient. We’ll be discussing more about HCPCS Level II codes in the next lesson. In this lesson, we’re concentrating on the Level I CPT codes.

The CPT code book that includes the Level I codes is broken down into six sections, each with a list of consecutive code numbers available to describe the procedures found in that section. Your text explains each section and the symbols and conventions that are used.

You’ll remember from studying the ICD-10 code books that all notes, symbols, indents, and headings have meaning and must be utilized in arriving at the correct code. Like the ICD volumes, the CPT manual has an index, which is the first place you should look when trying to determine an appropriate code. It’s important to remember to never to code solely from the index.