AMA CPT® Assistant - 2020 Issue 12 (December)
Bonus Edition: Frequently Asked Questions (December 2020)
December 2020 page 13 Bonus Edition: Frequently Asked Questions Evaluation and Management (E/M): Office or Other Outpatient Services Question: For the Current Procedural Terminology (CPT®) 2021 code set, will patient information still include history of present illness (HPI); past medical, family, and social history (PFSH); and review of systems (ROS)? Answer: The physician or other qualified health care professional (QHP) should perform all services that are medically appropriate for the patient and the patient’s medical condition, including HPI, PFSH, and ROS, if necessary. Although the physician’s work in capturing the patient’s pertinent history and performing a relevant physical...
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Article Overview
This premium article collects December 2020 frequently asked questions about CPT coding topics spanning office/outpatient evaluation and management, musculoskeletal and nervous system surgery, eye procedures, molecular pathology, psychiatry, ophthalmology, and neurology. It is useful for coders, billers, and compliance staff who need a high-level understanding of what types of services and scenarios were addressed in the CPT Assistant guidance for that period.
Why This Topic Matters
The article highlights coding topics that were changing or commonly questioned at the time, making it relevant for professionals comparing service documentation and procedure categories against CPT guidance. It can help readers quickly determine whether the full FAQ content includes the specialty area or service type they are researching.
Article Sections
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Evaluation and Management (E/M): Office or Other Outpatient Services
General questions about the 2021 office and outpatient E/M framework and the kinds of patient information discussed in that guidance.
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Surgery: Musculoskeletal System
Questions involving shoulder arthroscopy and related procedural considerations within musculoskeletal surgery.
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Surgery: Nervous System
Questions addressing nervous system procedure coding, including neurostimulation, nerve destruction, and related reportability issues.
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Surgery: Eye and Ocular Adnexa
A question about cataract surgery coding in the eye and ocular adnexa section.
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Pathology and Laboratory: Molecular Pathology
A molecular pathology question involving targeted sequencing and panel-based reporting concepts.
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Medicine: Psychiatry
A psychiatry question about whether a record-review service is included in psychotherapy code family guidance.
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Medicine: Ophthalmology
A question about ophthalmologic testing during intraocular lens-related care and use of an unlisted service code.
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Medicine: Neurology and Neuromuscular Procedures
A neurology question concerning guidance used during chemodenervation and whether it is separately reported.
What You Will Learn
- How this FAQ issue is organized across CPT specialty sections.
- Which broad coding topics were addressed in office/outpatient E/M guidance for 2021.
- What kinds of musculoskeletal, nervous system, eye, pathology, psychiatry, ophthalmology, and neurology questions were covered.
- How the article frames questions about unlisted services, related procedures, and specialty-specific reporting concerns.
Who Should Read This
- Medical coders
- Billing professionals
- Compliance staff
- Physician practices
- Revenue cycle teams
- Clinical documentation staff
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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