Health & Medical Health Care

How to Code CPT & ICD-9

    • 1). Read the patient's medical encounter form or medical record to familiarize yourself with the most recent visit.

    • 2). Identify the physician's diagnosis or reason for the patient's visit. If you are looking at the patient's encounter form, there should be a space for the diagnosis to be listed. If no diagnosis can be assigned at the end of the visit, note signs and symptoms as reasons for the visit to be entered in the place of a diagnosis.

    • 3). Identify any medical procedures or services that were performed. This can be found on the encounter form as well.

    • 4). Use the ICD-9 code book to look up any diagnosis codes. More than one may be listed. First look up the name of the diagnosis in the alphabetical section of the ICD-9 code book. Then double check the code referenced by looking up that number code in the tabular section located in Volume 1 of the ICD-9 code book. If you are coding from a patient encounter form, there may be only number codes listed for diagnoses. Look up these numeric codes in the tabular section as before to ensure that the diagnosis code matches the correct physician diagnosis.

    • 5). Look up any procedures, drugs or other medical services provided to the patient in the CPT code book. The patient will be assigned a code for the type of physician encounter (office visit, ER visit, outpatient surgery, etc.) and also codes for procedures or other services performed. Use the CPT codes just as you would the ICD-9 code book. First look up the procedure or service in the alphabetical index, then go to the numeric section and find the proper procedure. Read all notes carefully in the CPT book to make sure the code you assign exactly matches the one performed. These codes may also be listed on the patient encounter form. If so, look up these codes in the numeric section to ensure they are the same as the procedures performed on the patient.

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