Because “Someone Told Me” Isn’t an Authoritative Reference
If you have worked in medical coding for any length of time, you have probably heard some version of these statements: “That’s how we’ve always done it.” “That’s what I was taught.” “Our auditor said we can’t bill that.” “Medicare doesn’t allow it.” “I read somewhere that you have to code it this way.”
There is one question I think we should become more comfortable asking, can you show me the source? Not because we are trying to challenge someone, not because we are trying to prove someone wrong, and definitely not because we think we know everything. We ask because coding decisions should be supported by authoritative guidance—not simply passed from one person to another.
One of the most valuable skills we can develop as coders is not memorizing every coding rule, it is learning where to find the answer when we don’t know it. That is especially important in anesthesia coding. One question may require us to review the CPT® code set and another may lead us to CPT® Assistant. A Medicare question may take us into a CMS manual. A bundling question may require the National Correct Coding Initiative (NCCI), and sometimes, after all of that research, we still need to ask what does the patient’s payer require? The important part is understanding that these resources don’t necessarily answer the same questions.
Resource #1 — CPT®
Is Finding the Code Enough? We’ll start with the CPT® code set and talk about why finding a code whose descriptor matches the procedure may only be the beginning of the research.
Resource #2 — CPT® Assistant
When the Codebook Isn’t Enough. We’ll look at an additional AMA resource and discuss where we can turn when we need more context about CPT coding guidance.
Resource #3 — CMS & Medicare Manuals
Where Does CMS Actually Say That? Instead of stopping at “CMS says,” we’ll talk about how to trace Medicare guidance back to the actual manual, chapter, section, regulation, or program instruction.
Resource #4 — NCCI
When Two Correct Codes May Not Belong Together. Two services can be documented, and two CPT® codes can exist, but that doesn’t automatically mean they should be reported together. We’ll look at NCCI edits, policy guidance, and why our first question shouldn’t always be “What modifier will make this edit pass?”
Resource #5 — MAC & Payer Guidance
When the Payer Matters. Finally, we’ll bring everything together and discuss why identifying the correct CPT® code may still not answer questions about coverage, billing requirements, or reimbursement.
I don’t expect any coder to know every answer. I certainly don’t. What I want to know is Where can I find the answer, is the source authoritative, is it current, does it apply to this payer and date of service, am I using the source to answer the question it was actually intended to answer, and perhaps most importantly, can someone else follow my research and arrive at the same guidance? That’s the difference between saying “I think this is correct.” and being able to say “Here is the guidance I used and why I applied it.”
As we work through each resource, think about how you currently research anesthesia coding questions. When someone gives you an answer, do you accept it, do you ask for the reference, do you look it up yourself, and when you give someone else a coding answer, can you show them where your answer came from? Because “that’s how we’ve always done it” may explain a habit, but it doesn’t necessarily establish a coding rule. Don’t just give me the answer. Show me the source.
Come back tomorrow as we start with:
SHOW ME THE SOURCE — Resource #1
CPT®: Is Finding the Code Enough?
Let’s research it together.
Educational Disclaimer
This series is provided for educational and informational purposes only and is not legal, billing, compliance, or payer-specific advice. Coding and billing decisions should be based on the complete medical record, current official coding guidance, applicable payer policies, contractual requirements, and organizational compliance policies.
CPT® is a registered trademark of the American Medical Association.
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