When coding CPT, have you ever wondered where to look for official coding guidance, or whose rules you should be following?

Back in 1992, when I first started coding, the 1995 and 1997 guidelines didn’t even exist! We didn’t have any rules back then, or at least none that I can remember.

Today, lots of entities have their own sets of rules, and each set is different. Then, to add another layer, different payers have their own opinions and rules which adds stickiness to the situation. Boy have times changed!

Here are the CPT coding resources we use at Haugen.  Most of us have used these resources throughout our coding careers! Keep in mind that best practice is always to code as conservatively as possible, based on all available official advice.

Let’s look at some of these a little closer:

CMS: Many payers follow Medicare guidelines, so it’s important to follow Medicare guidance, edits and coverage determinations. In some circumstances, the AMA and CMS will offer differing guidance. In those cases, it is important to recognize which payer you are working with and follow guidelines appropriately.

MACs: MACs are private health insurers that have been awarded a geographic jurisdiction to process Medicare medical claims for Medicare Fee-For-Service (FFS) beneficiaries. Always use LCDs and guidance published by your specific MAC, located by your state.

AMA: The AMA creates and maintains the CPT® Professional Edition book and publishes several different types of helpful tools. The most popular one is the CPT Assistant, a newsletter that is issued monthly. When looking in your CPT® book you can see references to CPT Assistant articles, which give clarification to many codes throughout the CPT book. The AMA also offers other resources such as CPT® Changes: An Insider’s View and the CPT network and knowledge base for coding inquiries.

Specialty Societies: When CMS or AMA guidelines cannot assist you, information from specialty societies may help. Most physician specialties have one. For example, the orthopedics society is the American Academy of Orthopedic Surgeons (also known as the AAOS). The AAOS publishes a two-part book that contains information as to what is included in orthopedic procedures, which can be super helpful when coding. Much like the AAOS, many other societies exist, like the American College of Cardiology (ACC) and the American College of Radiology (ACR).

Reputable Organizations: There are many companies that offer coding guidance. Be diligent and do your research prior to trusting those sources.

Just remember, coding has lots of gray areas so it’s important that you can support whatever decision you make.

Mary Bort, CPC, CPMA, CANPC, CASCC, COSC

Mary Bort, CPC, CPMA, CANPC, CASCC, COSC

Consultant

Mary is a consultant for The Haugen Consulting Group with over 25 years of health care industry experience. She started her career in Orthopedics which was her passion for decades. In addition to Orthopedics, she provides expertise in other specialties such as Anesthesia, Ambulatory Surgery Center, as well as most surgical specialties . She has experience working the professional fee side of coding, audit, education as well as compliance, serving both coders and physicians, as well as the surgical side. She is a Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), Certified Anesthesia Professional Coder (CANPC) Certified Ambulatory Surgery Center Coder (CASCC) and Certified Orthopedic Surgery Coder (COSC).

During her free time, she loves to do crafts, enjoys the outdoors, and the Broncos! She has 4 daughters, and 10 grandchildren which light up her life.

1 Comment

  1. Danette Swanson

    This is an excellent resource!! I facilitate coding training through a grant for CO rural hospitals and their clinics and I’m going to make sure they all have access to this info and recommend they subscribe for future messages.
    Thanks so much!!

    Reply

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