Coding and documentation 101: current procedural terminology versus health care finance administration guidelines for office services

Abstract

Documentation and coding principles are intimately linked and affect patient care, reimbursement, and compliance. An understanding of the principles is required for the successful practice of medicine today. All physicians should receive formal education and practical training in chart documentation and coding of medical services. As with other medical knowledge, this education must begin early in training and be continually updated. This article will discuss documentation and coding in the ambulatory setting using Health Care Finance Administration and Current Procedural Terminology guidelines.