CPT Coding Questions And Answers With Verified Solutions

Accurate Assignment of E/M Codes - Identify place of service (POS). Identify type of service (TOS). Determine whether patient is new or established. Review documentation for level of service components. Apply CMS's Documentation Guidelines for Evaluation and Management Services Anesthesia Section - Anesthesia codes describe general anatomic area or service associated with surgical procedures. There is no one-to-one correspondence for Anesthesia to Surgery section codes. The same Anesthesia section code is often reported for different surgical procedures that share similar anesthesia requirements. Boldface type - Main terms in the CPT index are printed in boldface type. Note: CPT categories, subcategories, headings, and code numbers are also printed in boldface type. Category I CPT codes - Five-digit CPT code and descriptor nomenclature Organized in six sections Category II CPT codes - Reported to track performance measurements Use is optional. Category III CPT codes - Contains "emerging technology" temporary codesAssigned for data purposes Archived after five years unless accepted for placement Coding Procedures and Services - Step 1—Read introduction in CPT manual. Step 2—Review guidelines at beginning of each section. Step 3—Review procedure or service listed in the source document (e.g., patient record). Code what is documented in source document. Obtain clarification from provider if necessary. Step 4—Refer to CPT index, and locate main term for procedure or service documented. Main terms can be located by referring to: Procedure or service documented Organ or anatomic site Condition documented in the record Substance being tested Synonym Eponym Abbreviation Step 5—Locate subterms, and follow cross-references. Step 6—Review descriptions of codes, and compare qualifiers to descriptive statements. Step 7—Assign code number, applicable add-on or additional codes, and/or modifiers.Complete Procedure - When complete is found in code description, one code is reported to "completely" describe procedure performed. When complete is found in parenthetical note below code, it may be necessary to report more than one code to "completely" describe the procedure performed.