CPT®: Procedural Coding

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CPT®: Procedural Coding

Gail I. Smith, MA, RHIA, CCS-P


A broad and thorough understanding of the CPT coding system leading to correct and defensible code selection is essential for coders working in the outpatient setting or physician practices. Learn CPT coding with the unique perspective and expertise offered by nationally recognized CPT coding expert Gail I. Smith!

CEUs:  13    13 AHIMA    13 AAPC
Included in eLearning Library. Price per person. Group rates available.


A broad and thorough understanding of the CPT coding system leading to correct and defensible code selection is essential for coders working in the outpatient setting or physician practices. Learn CPT coding with the unique perspective and expertise offered by nationally recognized CPT coding expert Gail I. Smith!

CPT®: Procedural Coding provides a unique approach to mastering CPT coding.  Breaking it down to three steps of progressive learning, Gail I. Smith is your active instructional partner, teaching you what you need to know:

  1. Gain foundational understanding of the CPT coding system and its unique attributes
  2. Learn how CPT coding accurately captures procedures in the different body systems
  3. Practice your new CPT skills on real-world procedural cases

Step 1.  CPT: Procedural Coding starts with foundational knowledge.  Coders learn the principals governing accurate and complete CPT coding in any setting and any body system.

  • Organization and structure of CPT
  • Applying CPT guidelines for accurate code assignment
  • Abstracting information from a medical record and translating operative procedure notes to an accurate CPT
  • Understanding the unique tools within CPT to refine code selection
    • Correctly applying Modifiers including differentiating between physician-only and hospital outpatient modifiers
    • Evaluation and Management coding (including examples previewing the changes for 2021!)
    • Impact of NCCI edits
    • Medical necessity

Step 2. Armed with this foundational knowledge, coders learn CPT coding for a broad range of outpatient procedures:

  • General Surgery for all body systems: Integumentary, Musculoskeletal, Respiratory, Cardiovascular, Digestive, Urinary, Male and Female Genital, Nervous, Eyes and Auditory
  • Ancillary Services including: Radiology, Pathology, Laboratory
  • Medicine
  • Anesthesia
  • HCPCS Level II National Codes

Step 3.  Practice, Practice, Practice!  As a final step, coders put it all together and practice their CPT coding skills on 50 carefully selected real world outpatient surgical cases to reinforce learning and challenge coding skills.

CPT: Procedural Coding features:

  • On-demand, instructor-led, active learning featuring nationally recognized CPT coding expert Gail I. Smith. Let Gail show you how!
  • Critical decision-making skills and enhanced clinical knowledge to differentiate code selection.
  • Documentation drivers for accurate code assignments
  • Multi-media engaged learning.  Real-life coding scenarios supplemented with carefully selected video clips to illustrate the full range of surgical techniques used for outpatient procedures

CPT: Procedural Coding

Lesson 1: Introduction to CPT Coding
Differentiate between CPT, ICD-10-CM and ICD-10-PCS
Identify the purpose and use of CPT
Distinguish between CPT and National Codes (HCPCS)
Define Medical Necessity

Lesson 2: Format and Organization
Major Sections
Unlisted Procedures
How to Assign a Code

Lesson 3: Modifiers
Purpose of Modifiers
Physician vs Hospital Outpatient Modifiers
Appropriate Use
Common Modifiers
NCCI Edits

Lesson 4: Introduction to Surgery and Integumentary System
Define Surgical Package
Define Separate Procedure
Define Biopsy (fine needle aspiration vs core needle)
Given an operative report – learn how to apply coding guidelines and abstract clinical information to assign the correct codes.
Wound Repairs
Breast Procedures including Mastectomy

Lesson 5: Musculoskeletal System
Integumentary vs Musculoskeletal Coding for Tumors, Abscess and Hematoma
Drug-delivery devices
Joint Replacement

Lesson 6: Respiratory and Cardiovascular
Nasal Endoscopy
Laryngoscopy (direct, indirect and flexible)
Bronchoscopy and EBUS
Venous Access Devices
AV Fistulas and Grafts

Lesson 7: Digestive System
Upper and Lower Endoscopy Procedures
Removal of Tumors and Polyps
Colonoscopy Procedures
Surgical Treatment of Hemorrhoids
Hernia Repair
Image Guidance

Lesson 8: Urinary, Male and Female Genital Systems
Cystourethroscopy vs Cystoureteroscopy
Urinary System Calculi Procedures
Male Genital Lesion Removal
Prostate Procedures
Female Genital vs. Integumentary System
Urinary Incontinence Procedures

Lesson 9: Nervous System, Eyes, Auditory
Lumbar Puncture
Spinal Injections
Nerve Blocks
Spinal Neurostimulators
Peripheral Neurostimulators
Eye Procedures (Office, Emergency Room, Clinic)
Eye Section vs Integumentary Section
Ear Procedures (Office, Emergency Room, Clinic)

Lesson 10: Radiology, Pathology and Laboratory
Medical Necessity
National Coverage Determinations (NDC)
Professional and Technical Components
With/without contrast
Nuclear Medicine
Pathology and Lab
Panels and Assays
Surgical Pathology
Molecular Pathology
U Codes

Lesson 11: Medicine
Coronary Angioplasty
Cardiac Catheterizations
Injections and Infusions
Wound Care

Lesson 12: Anesthesia
Types of Anesthesia
Physical Status Modifiers
Add-on Codes
What is HCPCS
HCPCS Modifiers
Manual Process of HCPCS

Lesson 13: Evaluation and Management
New vs Established Patients
Key Components: History, Physical Exam, Medical Decision Making
Time as Principal Component
E/M Codes for the Hospital Setting
Brief overview of E/M for Critical Care, Prolonged Services, Nursing Facilities, Rest Home, Home Services, Non-Face-to-Face
Preventative Medicine
Modifiers for E/M Services
Bird’s Eye View of E/M for 2021

The level of effort to complete this course, start to finish, is equivalent to 13 CEUs and should take you approximately 13-39 hours to complete. Remember: You have access to the course materials for the full 16-week enrollment period and we encourage you to re-review any materials that are helpful to you.

Certificate of Completion
Upon successful completion of the course work, student will be able to download a Libman Education Certificate of Completion. The Certificate of Completion will list the course as awarding 13 CEUs.

This course has been approved for continuing education units (CEUs) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.

This program has the prior approval of AAPC for continuing education hours. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.

  • WebinarPlus™ multimedia and interactive online course promotes engagement with challenging materials while offering independent self-study.
  • Teaching methods including audio and video files, diagrams, and animations to accommodate different learning styles. Where appropriate, the Merck Manual Professional Version supplements course materials with in-depth descriptions of diagnoses and/or procedures.
  • Knowledge checks and/or final assessment ensure mastery of material.
  • Online Flexibility! Materials available via secure Learning Management System (LMS). Work at your own pace — save time and travel costs.
  • Earn Libman Education Certificate of Completion and CEUs.
  • To receive CEU credit, students must achieve a passing rate on the course assessment(s).
  • Course is self-paced. For planning purposes, assume 1-3 hours required for each CEU.
  • Unlimited course access during enrollment period. For courses offering greater than one CEU, enrollment period is 16 weeks. For courses offering one or fewer CEUs, enrollment period is 4 weeks. Courses purchased as a bundle or package may have a longer enrollment period.
  • Extensions to the enrollment period are available. Contact Libman Education for pricing.
  • Price listed is per person/per course. Group rates available upon request.

Gail I. Smith, MA, RHIA, CCS-P Gail I. Smith, MA, RHIA, CCS-P

Gail Smith, president of Gail I. Smith Consulting, is a nationally recognized coding educator. For most of her career Gail was an associate professor and director of the health information management (HIM) program at the University of Cincinnati and HIM program director at Cincinnati State Technical and Community College. Gail is a currently a consultant with a software company specializing in medical terminologies. Gail has authored several textbooks, including Basic Procedural Terminology and HCPCS Coding published by the American Health Information Management Association (AHIMA).

An advocate for advanced coder training, Gail is the author of several titles for Libman Education including CPT: Introduction to Procedural Coding and two courses on the unique challenge of CPT coding in the pediatric setting: CPT for Pediatrics and CPT for Pediatrics: Advanced Orthopedic Coding. According to Gail: “One cannot possibly teach every coding scenario a coder will experience in their career. That is why coding education needs to focus instead on how to arrive at an accurate and defensible code assignment. It is the difference between learning to fish, and being given a fish. If you learn to code instead of being given answers to memorize, you will be able to arrive at the complete codes more quickly and with greater confidence.”

“So glad to hear that Gail will be leading this course. She is an exceptional educator.” — HIM Practitioner, on Gail’s course CPT: Introduction to Procedural Coding

“I have completed the CPT update course and loved it. Pairing the audio with the visual works well for my learning style. It was well worth the money for me to spend. Much better than the quickie, run-through-everything-in-an-hour CEU offerings work allows us.” — Karin A., MPS, RHIT, CPC-I, CPC, CMA, PBT, Professional Coding Quality Specialist, on Gail’s course CPT® Code Updates

“by the way, Gail’s course is great, I am enjoying!” — HIM Director on Gail’s course ICD-10-CM for Coding Professionals

“I recently completed the CPT Update for 2017. I thought it was a wonderful course. It is so important as a coder that I know and understand the changes each year. This course was very helpful to me.” — Marcelette on Gail’s course CPT® Code Updates

“Gail Smith is one of my favorite resources, the work that your team is doing is outstanding and professional, Thanks again, for your help” — HIM Coder

“I truly thank you Libman Group for your wonderful courses that have contributed to my success.” — Leslie Jay Corn, CCS, CPC, CCA/ER Coding Analyst/Boston Medical Center OR LogixHealth

“I’m pleasantly surprised at your response … really didn’t think I would receive anything at all, so, thank you! I believe that alone says a lot for Libman Education. I would recommend you to other coding professionals.” — Jennifer Jones, CPC

“LOVEEE Libman! Very happy with the classes I’ve taken.” — Linda C.

“Any of Libman Education’s courses are worth time and cost. Always walk away with a useable, clarity or reinforcement of subject matter.”

“I greatly appreciate this support and outstanding customer service!” — former student


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