How to Document CPT Codes in Medical Billing

Current Procedural Coding (CPT) is a process of allocating five digit numerical codes to medical treatments, procedures and services provided by doctors or health care professionals. The codes are maintained for billing and keeping progress of the services. After that CPT codes are documented to the health insurer during the process of medical billing in order to facilitate the people by reimbursing for treatments applied to patients. On the other hand, CPT codes are generally updated on a yearly basis and printed by the AMA (American Medical Association). There are a number of ways to document CPT codes in medical billing with good effect.


  • 1

    Getting started

    Look over the patient documentation for services, procedures and treatments. Review doctor’s notes, operative findings and other provider information that consists of the treatments performed on the person in full detail. Keep notes on the treatments, procedures and services that were done on the individual. Be aware of the fact that it is strongly advised to note down the coding in the patient’s medical record. Moreover, it is always better to use a scrap sheet of paper to generate coding notes until the codes are allotted for the patient.

  • 2

    Study the CPT code book

    Read up the treatments, procedures or services performed on the coding software or the CPT code book. Begin with the procedure performed or with the body system. For instance, if a bunionectomy of the toe was done, the assigned code or codes can be looked in the CPT code book index by searching for “Bunion Repair” or even by looking up “Toe, Repair, and Bunion.” On the other hand, allocate the most similar CPT code to every treatment done on the patient. You also need to check and analyse the procedure performed and discuss it with the physician for a better picture of treatment.

  • 3

    Ask questions from the medical examiner

    Be aware of the fact that you always need to gather more details and information by checking for inconsistencies in the procedure with the provider or doctor. You can also review questions from him. A coder should not interpret details about a treatment that is not listed on the database or guess at all times. Give the CPT code assignments on the form for billing purposes. Most of the insurers are billed electronically. As a result, codes are entered over the internet and sent from the web to the payer.

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