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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

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