AMA CPT® Assistant - 1998 Issue 1 (January)

Documentation Guidelines, Correlating Exam Level to Documentation (Q&A) (January 1998)

January 1998 page 11c Coding Consultation Documentation Guidelines, Correlating Exam Level to Documentation (Q&A) Must a physician indicate in the medical record which exam is being used so a reviewer would know which bulleted exam elements would be required for a given level of exam? AMA Comment CPT code reporting is based on the documentation submitted. If the documentation substantiates a particular level, reporting is correlated accordingly. Documentation Guidelines, Correlating Exam Level to Documentation (Q&A). CPT® Assistant. 1998; January 1998 page 11c ...

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CPT® Assistant content is the official source for CPT® coding guidance. It is an instrumental tool when appealing insurance denials and validating coding to auditors. Monthly issues and an extensive archive provide comprehensive guidance on proper CPT® coding for past, present and upcoming code set releases. Archives date back to 1990 for historical use of codes, changes, rationales, coding tips and trends in the industry.

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