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The The Complete Procedure Complete Procedure
Coding BookCoding Book
By By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHAShelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA
Chapter 2Chapter 2
Introduction to Coding and CPTIntroduction to Coding and CPT
• Use official guidelines provided to apply the best code.
• Follow the organization of CPT to determine the best code.
• Comply with notations and symbols to code accurately.
2 - 3
IntroductionIntroduction
Coding is interpreting health care terms and definitions into numbers or number/letter combinations that specifically relate to diagnoses and procedures.
2 - 4
Medical NecessityMedical Necessity
• Diagnosis codes report the reason why the physician provided the service or treatment.
• Diagnosis codes explain the medical necessity of providing the service or treatment.
2 - 5
ProceduresProcedures
• Procedure codes report what the physician provided for the patient.– CPT codes– HCPCS Level II codes– ICD-9-CM volume 3• Services, treatments, counseling,
surgery, testing, etc.
2 - 6
CPTCPT
CPT stands forCurrent Procedural
Terminology
Developed and maintained by the American Medical Association
2 - 7
Steps to Accurate CodingSteps to Accurate Coding
1. Read through the notes completely.
2. Highlight key words.3. Query the physician
regarding any confusing, conflicting, or missing information.
2 - 8
Steps to Accurate CodingSteps to Accurate Coding
4. Code the diagnoses.5. Code the procedures.
- Look up key words relating to WHAT the physician provided.
- Verify the code’s description.
6. Link every procedure code to at least one diagnosis code.
2 - 9
Coding From Physician’s Coding From Physician’s NotesNotes
• More accurate than coding from a superbill.
• More complete than coding from a superbill.
• Official guidelines state that coding should be done from notes and not superbills.
2 - 10
CPT Coding BookCPT Coding Book
Report • Physician services• All procedures performed in
an outpatient facility– Physician’s office– Ambulatory care center– Clinic
2 - 11
Organization of CPTOrganization of CPT
• Sections of the main body of CPT– Evaluation and Management– Anesthesia– Surgery– Radiology– Pathology– Medicine
2 - 12
Organization of CPTOrganization of CPT
• Second part of CPT includes- Category II codes
- Category III codes
- Appendixes A through I
- Alphabetic index
2 - 13
Alphabetic IndexAlphabetic Index
• Procedures, services, and treatments listed by:• Procedure or service• Anatomical site• Condition• Eponym, synonym, or
abbreviations
2 - 14
Official GuidelinesOfficial Guidelines
• Guidelines are located:• In front of each of the six
CPT contains thousands of codes used to report services, treatments, and procedures. The book includes guidelines for each section, as well as notations, symbols, and references to assist you in reporting the most accurate code.