How Do You 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). 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. 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. Look up the procedures, treatments or services performed in a CPT code book or on
