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How I cracked the CPT codes


We think you'll like this young doctor's down-to-earth system, even if you don't want to try it yourself.


How I cracked the CPT codes

We think you'll like this young doctor's down-to-earth system, even if you don't want to try it yourself.

By Shawn L. Ralston, MD
Pediatrician/Los Lunas, NM

I came out of my pediatric residency ready to take on anything: I couldn't wait to make my own decisions, be my own woman, call my own shots.

On my first day in my own practice, I kept dancing around thinking, "Yippee! I get to do whatever I want!" I felt prepared by my residency for any eventuality. Give me respiratory distress! Acute neurologic deficits! Broken bones! A code! I was ready for the toughest of clinical challenges.

Yet right off the bat, I was floored by a problem more stubborn than any I had encountered in residency. It wasn't a code that got me. It was coding.

Why had nobody ever told me anything about the intricacies of coding? I had so many questions:

What if the expanded problem-focused history led to an expanded problem-focused exam, but required only minimal risk to treat?

Is it standard to code for a yearly physical exam and for the medical treatment you give for a separate condition?

What if I sew up a kid's laceration and treat his asthma, as well? What if he's also constipated and has a rash?

What if I read my own X-ray, but also send it to a radiologist for confirmation?

What does RBRVS mean?

Which section do I use to code a Medicaid physical exam?

How can anyone do this 30 times a day?

What kind of sadist came up with this scheme?

Pretty soon, I began to look back on the five months of my residency spent in intensive care units, and to wish I had spent the time learning how to code, instead.

Finally, after several confusing discussions with our clinic's medical director, I settled on a ridiculous—but highly effective—coding method. It's based solely on my level of aggravation as I complete an exam. The simplified version is as follows:

  • Smile on my face = problem-focused.

  • Furrowed brow and slight frown = expanded problem-focused.

  • Nasty, throbbing headache = detailed.

Sometimes I supplement the aggravation-based method with a chart-based one. For instance, on busy days, I can effectively code a visit based on the number of charts that pile up waiting to be looked at while I'm in with a patient. One to two charts means the visit was problem-focused. Three to five is definitely expanded problem-focused, and more than five generally means detailed.

Each method seems equally effective and at least as accurate as my attempts to pick winning lottery numbers in order to pay back my student loans. Of course, I'll probably soon need to start picking more lottery numbers to pay to defend against charges of Medicaid fraud. But for now, I feel I've conquered at least this one aspect of the coding dilemma.

Unfortunately, my problems with coding were mirrored in referrals and lab tests. Specifically: If I didn't choose the "correct" diagnostic terms, referrals and lab tests would be disallowed.

I've learned, for example, that there's a big difference between "obesity" and "abnormal weight gain"—one gets my referral to a nutritionist covered, and the other just gets someone teased by fifth-graders (I'll leave you to ponder which is which).

Trying to be smart with my diagnoses always turned out to be a mistake. "Myopia" as a basis for a referral for glasses was refused since I am not an ophthalmologist. But the referral was rapidly approved after I changed the diagnosis to the very primary-care-appropriate "visual difficulties." Never mind that the child reads everything four inches from his face and has 20/80 vision.

After all those years of struggling to be as specific as possible with my diagnoses, I had to struggle anew to become less specific in order to get paid. Somebody sure could have saved me a lot of time if they had clued me into this a long time ago!

Finally, after a few months, I began to practice a certain anti-logic when applying diagnostic terms, and suddenly everything was covered. I now refer for an upper GI series, psychiatric counseling, or herniorrhaphy equally well with the simple and very nonspecific diagnosis "abdominal pain," and the visits are always approved.

I sometimes find it a little odd that a diagnosis of fatigue allows me to order every blood test our laboratory offers, while the more descriptive "microcytic anemia" won't even get me a ferritin half the time. And it's fascinating that both constipation and temper tantrums will get a child seen by a neurologist.

Still, I do occasionally come across a dilemma. For instance, I thought long and hard about what to call the visit I had recently with a 4-year-old who had glued his eyelids shut with Krazy Glue.

And then it came to me—"visual difficulties" would do just fine.


Shawn Ralston. How I cracked the CPT codes. Medical Economics 2002;4:26.

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