Identify the Correct CPT Code and Modifier

Abstract

Using the data collected in the previous three steps, the correct E/M CPT code can be determined. In Step 1, the patient location and type were identified. These two characteristics gave us the first four digits of the correct code. In Step 2, the level of medical decision making involved in the encounter was determined. Medical decision making can be straightforward (SF), low complexity (LC), moderate complexity (MC), or high complexity (HC). In Step 3, the levels of history and examination were determined. Both may be problem focused (PF), expanded problem focused (EPF), detailed (DET), or comprehensive (COMP).