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Steps For CPT Coding
From Handout on 1/25/2010. Eight steps for getting the proper CPT code. These must be listed in order.
determine the category and subcategory of service based on the location of service and the patient's status
determine the extent of the history that is documented
determine the extent of the examination that is documented
determine the complexity of medical decision making (MDM) that is documented
analyze the requirements to report the service level
review the nature of the presenting problem and the time spent with the patient
verify that the documentation is complete
assign the code