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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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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