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CPT GUIDELINES

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on 25 October 2013

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Transcript of CPT GUIDELINES

CPT GUIDELINES
Current Procedural Terminology, otherwise known as CPT, is the handbook used in order to properly code procedures performed by doctors. It is subject to a number of guidelines and tribulations that make it efficient.
General Purpose of CPT Guidelines
Each section has their own specific guidelines
Purpose of guidelines is for those who use the CPT manual to better understand each section and subsection
Anesthesia Guidelines
All items used by all physicians in reporting services are presented in the Introduction.
Seperate or Multiple Procedures - When multiple surgical procedures are performed, the anesthesia code representing the most complex procedure is reported
Time Reporting - Time for anesthesia procedures may be reported as is customary in the local area
Pathology and Laboratory Guidelines
Services in Pathology and Laboratory - Services are provided by a physician or by technologists under responsible supervision of a physician
Separate or Multiple Procedures - It is appropriate to designate multiple procedures that are rendered on the same date by separate entries
Sections and Subsections
Guidelines refer to the entire section
Subsection guidelines are listed as 'Notes' at the beginning of each subsection
Each section is unique and each have their own specific guidelines
State a Chief Complaint - Concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter
History of Present Illness - Chronological description of the development of the patient's present illness
Family History - Review of medical evens in the patient's family
Social History - Age appropriate review of past and current activities
Surgery Guidelines
Supplied Materials - Over and above those usually included in the procedure(s) rendered are reported separately
Special Report - A service that is rarely provided, unusual, variable, or new may require a special report
Surgical Destruction - A part of a surgical procedure; not ordinarily listed separately unless the technique substantially alters the standard management of a problem or condition
Medicine Guidelines
Add-on Codes - Some of the listed procedures are commonly carried out in addition to the primary procedure carried out
Separate Procedures - The codes designated "separate procedure' should not be reported in addition to the code for the total procedure or service of which it is considered an integral component
Unlisted Service or Procedure - A service or procedure may be provided that is not listed in this edition of the CPT codebook
There are six sections in the CPT manual with six different main guidelines, also known as Section Overviews
Six sections of the CPT manual are:
1.Evaluation and Management
2.Anesthesia
3.Surgery
4.Radiology
5.Pathology & Laboratory
6.Medicine
Section Overviews
Section Overview for E/M : Important Guidelines
Radiology Guidelines
Subject Listings - Apply when radiological services are performed by or under the responsible supervision of a physician
Written Reports - Signed by the interpreting individual should be considered an integral part of the radiologic procedure or interpretation
Unlisted Service or Procedure - A service or procedure may be provided that is not listen in this edition of the CPT codebook
Conclusion
The guidelines in the CPT code book are meant to help guide those who use it in order for them to be able to use it appropriately with as little error as possible. Each section in the CPT has its own guidelines that are in accordance to each procedure. This comes from years of annual editing and it has gotten to the point of precise and concise coding. It is important to follow these guidelines accordingly in order to ensure utmost perfection in coding.
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