Even if only one code is present, the coder must refer to the main term to ensure that the code is selected accurately and correctly to identify the services rendered.
Main Terms
The index is organized by main terms. Each main term can stand alone or can be followed by up to three modifying terms.
There are four primary classes of main entries,
- Procedures or Services - E.g, Scopic, Anastomosis, Splint, Opening
- Organ or Other Anatomical Site - E.g, Knee, Arm, Ear, Tibia, Colon
- Conditions - E.g, Abscess, Entropion, Tetralogy of Fallot.
- Synonyms, Eponyms, and Abbreviations. - ECG, EEG, PET, Brock Operations, Clagett Procedures
Modifying Terms
The main term may be followed by up to three indented terms that modify the terms they follow.
EG. The main term "Endoscopy" is subdivided by the anatomical sites in which the procedure is used. And within these anatomical sites, the specific purpose of the procedures is identified.
EG. The main term "Endoscopy" is subdivided by the anatomical sites in which the procedure is used. And within these anatomical sites, the specific purpose of the procedures is identified.
In the following example, The code for endoscopic removal of a foreign body from the bile duct could be located.
- Bile Duct
- Removal
- Foreign Body........ 43275
Code Ranges
Whenever more than one code applies to a given index entry, a code range is listed. If several inconsequential codes apply, they will be separated by a comma. In the following example, three inconsequential codes apply,
- Esophagus
- Reconstruction ......... 43300, 43310, 43313
- Anesthesia
- Forearm...............01810-01820, 01830-01860
Conventions
As a space-saving convention, certain terms carry meaning inferred from the context. This convention is primarily used when a procedure or service is listed as a sub-term.
Example,
- Knee
- Exploration .............. 27310,27331
Pathology & Laboratory Codes
The pathology and Laboratory listing in the index presents the headings, subheadings, procedures, and analyzes in the Pathology and Laboratory action of the CPT codebook.
Analytes are either listed alphabetically or cross-referenced to the index main heads where they are alphabetically listed.