1. Identify the procedure, tests, services, etc. from the source document (i.e., medical record, superbill, etc.). Look for any modifying or extenuating circumstances.
2. Identify main terms and subterms.
3. Locate the procedure or service in the Index by checking procedure, anatomic site, synonym, eponym or abbreviated entries.
4. When you have found the entry in the Index, identify the code number next to it and refer to that code section in the main body of the manual. Be sure they match.
5. If a range of codes is given for the procedure, read the description of each entry within the range to make the proper selection that matches or fits as closely as possible to what was actually done.
6. NEVER code directly from the Index! Always verify codes in the main body of the CPT.
7. Ensure you have followed all notes and guidelines at the beginning of the section.
8. If the exact code is not what you are looking for, you may want to use a modifier.
9. If there is not a proper code, you may have to use the unlisted procedure codes in that section. Only use these as a last resort.
CPT Coding Examples
For inexperienced CPT coders to become oriented to the CPT manual, it is recommended to search for procedures with the help of the Index. The Index is printed in the CPT manual in the end pages of the book. The Index is organized by main terms. Each main term can stand alone, or be followed by up to three modifying terms.
The Index is NOT a substitute for the main text of the CPT codebook. Even if only one code appears, the user must refer to the main text to ensure that the code selection is accurate