An Introduction to CPT Coding: CPT Guidelines and Notes

Outline:

Section 1: Introduction

About This Course

Learning Objectives

Section 2: Overview of CPT Coding Guidelines

Guidelines for Coding

Coding Guideline Sources

Coding Guidelines: CPT Versus CMS

Correct Coding Guidelines

General CPT Coding Guidelines

Review

Section 3: Evaluation and Management (E/M) Guidelines

Evaluation and Management Services

Classification of E/M Services

Definitions of Commonly Used Terms

E/M Guidelines

Digital Medicine Services

Review 

Section 4: Anesthesia Guidelines

Anesthesia Services

Anesthesia Guidelines

Anesthesia Modifiers

Qualifying Circumstances

Review

Section 5: Surgical Guidelines

Surgical Services

Surgical Guidelines

Surgical Package

Review

Section 6: Ancillary Services Guidelines

Ancillary Services

Radiology Services

Radiology Guidelines

Radiology S&I and Contrast Guidelines 

Pathology and Laboratory Services

Pathology and Laboratory Guidelines

Review

Section 7: Medicine Section Guidelines

Medicine Section Services

Medicine Section Guidelines

Review

Section 8: Conclusion

Course Summary

Course Contributors

Resources

References

Sarah is a Subject Matter Expert/Writer for Relias's Revenue Cycle and Coding online education. Sarah is credentialed by AHIMA as a Certified Coding Specialist (CCS) and Certified Coding Specialist Physician-based (CCS-P), as well as an approved ICD-10-CM/PCS Trainer. She is also credentialed by AAPC as a Certified Professional Coding Instructor (CPC-I), a certified coder of physician/professional (CPC) and outpatient hospital services (COC), and a Certified Risk Adjustment Coder (CRC), with specialty certification in Evaluation and Management Services (CEMC). Sarah has extensive experience in both professional and facility ICD-10-CM/PCS, CPT and HCPCS coding, auditing, and revenue cycle management and as an educator of hospital and professional medical coding curriculum. She has served as Director of Physician Billing and Reimbursement for a regional health system, Manager of Coding and Compliance for a hospital and cancer center, and Business Manager of Physician Practices at a teaching hospital, as well as a coding auditor and consultant. Sarah has also authored coding textbooks and instructional resources.

Disclosure: Sarah A. Serling, CCS, CPC, CRC, COC, CCS-P, CEMC, CPC-I, ICD-10-CM/PCS Trainer has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.

Andrei is a healthcare coding analyst in the CPT Education and Information Services Department at the American Medical Association, a staff writer for CPT Assistant, and a contributing author of the Principles of CPT Coding textbook. He has been a Registered Health Information Technician since 2009 and an active AHIMA member. He has gathered experience and developed skills by working in health insurance, at third-party payers, and in top-ranked national health care organizations. He completed an AAS in Health Information Technology from DeVry University in 2008 and a BS in Biology from Georgia Gwinnett College in 2015. In his spare time Andrei enjoys traveling, reading, playing the piano and the pipe organ.

Disclosure: Andrei Besleaga, BS, RHIT has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.

Arletrice is a senior healthcare coding analyst in the CPT Education and Information Services Department and staff writer for CPT Assistant. She supports and assists with other department projects on an as-needed basis, and she is also a contributing author of the Principles of CPT Coding. She has been with the AMA for over 14 years. She has been an educator since 2002 in health information technology (HIT) and is currently a health care administration adjunct instructor at an online university. She earned a BS in Health Information Administration from the University of Illinois at Chicago, IL, and a Masters of Healthcare Administration from the University of Phoenix, AZ. She is also certified as a registered health information administrator from the American Health Information Management Association (AHIMA), as well as an AHIMA-approved ICD-10 CM/ PCS trainer.

Disclosure: Arletrice A. Watkins, MHA, RHIA has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.