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.
- Centers for Medicare and Medicaid Services (CMS)
- Outpatient Prospective Payment System (OPPS) publications (for hospital coding)
- Medicare Physician Fee Schedule (MPFS) (for professional fee coding)
- The Medicare Learning Network (MLN), publications and MLN Matters Articles
- National Coverage Determinations (NCDs)
- National Correct Coding Initiative (NCCI) Edits and Policy Manual
- Medically Unlikely Edits (MUEs)
- Program memoranda
- Local Medicare Administrative Contractors (MACs)
- American Medical Association (AMA)
- CPT book (published annually with online errata)
- CPT Changes: An Insider’s View (published annually)
- CPT Assistant (published monthly)
- CPT Knowledge Base (online)
- American Hospital Association (AHA)
- Coding Clinic for HCPCS (for hospitals)
- Specialty Societies and Reputable Organizations
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
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.