July 18, 2024


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How CPT Terminology Can Ensure Accurate Coding And Increased Reimbursement

How CPT Terminology Can Ensure Accurate Coding And Increased Reimbursement

We as coders know all too well the importance of appropriate documentation for fair and appropriate payment for the services that are performed by the physicians. It is just as important, however, to use correct CPT® terminology when listing those procedures at the top of an operative report.

This can be difficult, however, since the words used to describe procedures and conditions in CPT® and ICD-9 can differ from the clinical terminology that physicians use to dictate the procedure. Although coders must always read the complete operative report, and especially focus on the procedure notes, many coders ignore to do so. This can cause them to report the procedure inaccurately and get denials or low reimbursements.

As a result, the words and descriptions that the physician uses in his notes assume much more importance. However in cases when the physician doesn’t dictate in a language similar to the one used in CPT® or ICD-9 manuals, many coders can find themselves lost in the complicated – and at times, incomprehensible – report. This can cause you an incorrect CPT® codes look up, a lower – or higher -reimbursement, audits and even OIG attacks, delays in getting the bills out, and denials by carriers; and internally it can also make it difficult and more expensive to provide training to the staff.

Correct Terminology Can Reduce Denials

Insist that your physicians use CPT® and ICD-9 language. As stated above this will help your practice reduce revenue loss (or inappropriate gain) and speed the billing process. In addition, this can also decrease denials and protect your practice during subsequent audits.

Know The Terminology Yourself

Whether or not you have undertaken any formal training in coding, you must know your medical terminology to stay in the loop. If you can’t understand what your physician is talking about or mentions in his notes, you’re not doing the best you can at your coding office.

You can try learning medical terminology on your own or take an educational course to actually simplify your life in office. If you don’t know the medical terms, you can have a difficult time understanding the physician as well as the patients’ needs.

You must also consider that terms and medical CPT® codes are intentionally precise in their description of a diagnosis, procedure, or even the examination findings. With a proper knowledge of terminology, you can understand the physician’s notes accurately.

You can visit these Web sites to beef up your medical terminology:

  • To test your knowledge of the medical words and take some quick quizzes, visit the University of Minnesota’s Web site
  • You can buy a copy of the “Quick and Easy Medical Terminology” by Peggy Leonard at your local bookstore.
  • To know how to pronounce the medical terms, try the Merriam-Webster dictionary to know the meaning as well as hear the pronunciation. Simply type in the medical term, and your computer will speak to you with the correct pronunciation.