Certified Inpatient Coding (CIC) Practice Exam

Which coding system is primarily used for documenting outpatient procedures?

1. ICD-10-CM

2. CPT®

3. HCPCS

4. SNOMED-CT

The correct answer is: CPT®

The coding system that is primarily used for documenting outpatient procedures is the CPT® (Current Procedural Terminology). CPT® codes are specifically designed to report medical, surgical, and diagnostic services and procedures performed by healthcare professionals during outpatient visits. They provide a uniform language that conveys specific information about the procedures and services rendered, ensuring clarity and consistency in billing and medical documentation. While ICD-10-CM is used for coding diagnoses, and HCPCS includes codes for various healthcare services, supplies, and equipment, it is the CPT® system that is most relevant for outpatient procedures, as these codes detail specific actions taken during patient visits. SNOMED-CT is a comprehensive clinical terminology but not focused specifically on billing or documentation of outpatient procedures. Therefore, CPT® is the most appropriate choice for this context.