Which manual is utilized specifically to code a patient's office visit?

• A. HCPCS
• B. DSM-5
• C. ICD
• D. CPT (Current Procedural Terminology)

Answer: (D)

CPT codes are used to describe the actual service performed during an office visit. They come from the Current Procedural Terminology system, which provides the specific codes and levels of service for professional medical procedures and encounters, including outpatient evaluations and management visits. The code chosen reflects the complexity and content of the visit (for example, level of history, exam, and medical decision making) and is what payer systems use for billing the clinician’s work. Diagnoses behind the visit are captured separately with ICD-10-CM codes, which explain the reason for the visit but do not describe the service performed. DSM-5 is a psychiatric diagnostic manual, not a billing coding system, and HCPCS covers items like supplies and some nonphysician services, not the standard office visit service. So, the manual used specifically to code an office visit is CPT.