Part 1
Current Procedural Terminology (CPT) was created by the American Medical Association (AMA) in 1966 (Vines et al., 2017). The CPT is a set of descriptive medical codes used by physicians, outpatient facilities, healthcare providers, laboratories, hospitals, and non-physician practitioners (Vines et al., 2017). These codes help provide a detailed description of services, including the medical, surgical, and diagnostic procedures performed (Vines et al., 2017). This information is used for insurance claims processing, evaluation, and the creation of guidelines on healthcare utilization (Vines et al., 2017). In 1983, the CPT nomenclature was implemented by the Centers for Medicare and Medicaid Services (CMS) to report a detailed description of the services provided in the Part B Medicare plan (Vines et al., 2017).
The state Medicaid agencies in the Comprehensive Budget Coordination Act of 1986 requires state Medicaid agencies to use CPT codes for reporting on outpatient procedures (Vines et al., 2017). CPT codes are divided into categories one, two, and three. Type one is a five-character code that has been approved by the Food and Drug Administration (FDA) (Vines et al., 2017). These codes include a detailed description of the specific program or service being executed (Vines et al., 2017). To help improve the accuracy and convenience of coding the AMA has clustered similar codes (Vines et al., 2017). Category two codes are supplementary codes, which are four letters in length and end with F (AAPC, 2021). It is recommended that these category two codes be used as performance tracking, compliance, and quality assessment measures (AAPC, 2021). Category two codes are not linked to reimbursement (AAPC, 2021).These measures are used to improve performance and accountability (AAPC, 2021). Category three codes are codes that are temporary, experimental in nature, and representative of new emerging services, technology, or procedures (AAPC, 2021). CPT codes are indented with numerous modifiers and include subdivisions, and semi colons used for separation purposes (AAPC, 2021). The code set is used to provide the most accurate specificity for maximum compensation and prevention of partial compensation or rejection (AAPC, 2021).
Part2
Electronic medical records are very helpful to not only patients and providers. Patients can access their medical records, review labs, see diagnosis, and office or medical procedures with the click of a button. Patients have the access at their fingertips without having to wait a nurse to call with results. Electronic medical records have made it easier on doctors to schedule procedures, order labs, and submit notes. Doctor’s notes can be viewed by others doctors within the same healthcare program. Patients often see different doctor’s for different comorbities and each doctor can access all records including medications. Electronic medical records has given the ability for both patient and doctor to have access to their records without having to wait on copies and a medical records department to send those records.