- The CPT Manual, which lists all available procedure codes, is divided into anatomical sections including sections, such as circulatory and endocrine (see link in References). In addition to body systems, there are also lab procedure codes and codes for radiological procedures. Some procedures require multiple codes from more than one section of the CPT manual. For example, an aortic aneurysm repair requires circulatory codes as well as codes for radiological guidance.
- All codes include a procedure description. Many descriptions sound similar but differ in application or in reimbursement if used for billing purposes. Never bill for a higher priced procedure if the documentation does not clearly support a more involved procedure. For example, there are multiple codes for chest X-rays. A one-view chest X-ray is coded as "71010." A two view chest X-ray is coded for higher reimbursement as "71020." Unless the report clearly states two views, the one view code must be used.
- Many procedures require several steps. It is tempting to assign a separate procedure code for each step, but Medicare and many other payers bundle incidental steps, such as the initial incision and X-ray guidance into one primary procedure code. Separating the procedures into many procedure codes, called unbundling, is against Medicare regulations and can result in fines and penalties include removal from the Medicare and Medicaid programs. It is up to the coding professional to keep abreast of bundled code changes and to code the records accordingly.
