A clinical documentation integrity practitioner (CDIP) is reviewing an outpatient surgical chart.

The coding reference that should be used for coding advice on correct assignment of the procedure code for proper ambulatory payment classification (APC) reimbursement is the AMA CPT Assistant. The CPT Assistant is the official source of guidance from the American Medical Association (AMA) on the proper use and interpretation of the Current Procedural Terminology (CPT) codes, which are used to report outpatient and professional services. The CPT Assistant provides clinical scenarios, frequently asked questions, coding tips, and updates on CPT coding changes. The CPT codes are used to determine the APC reimbursement for outpatient services under the Medicare Outpatient Prospective Payment System (OPPS). (CDIP Exam Preparation Guide)

References:

CDIP Exam Content Outline1

CDIP Exam Preparation Guide2

AMA CPT Assistant3

Medicare Claims Processing Manual Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS)