The first thing that I would do is to read the note and identify the location, type of patient, type of service, what was done. Take your pen or pencil and underline the key points in the note.
The patient type would be like new or established, and age.
Location of service would be like office/Outpatient clinic, ED, hospital, etc
What services and supplies were ordered and performed.
All of these and more will be in your CPT 2009 manual.
Think of it this way, whatever the MD does with the patient, you want to code properly for the services they have done, you would never just use one code otherwise you may have discounted the services the MD has done, thus receiving a low reimbursement...ouch!!
Study the concepts in each section of the CPT book, start with the E&M section it will give you more info about what I have mentioned above.
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