When billing for a patient’s visit, codes are selected that best represent the services furnished during the visit. The two common sets of codes that are currently used are:
1. Diagnostic or International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) codes; and
2. Procedural or American Medical Association Current Procedural Terminology (CPT) codes.
These codes are organized into various categories and levels. It is the physician’s responsibility to ensure that documentation reflects the services furnished and that the codes selected reflect those services. The more work performed by the physician, the higher the level of code he or she may bill within the appropriate category. The billing specialist or alternate source reviews the physician’s documented services and assists with selecting codes that best reflect the extent of the physician’s personal work necessary to furnish the services.
CPT billing codes
CPT codes and HCPCS codes
What is Medical coding
