AMA CPT® Assistant - 1998 Issue 1 (January)

Documentation Guidelines, Comprehensive Level/Single Organ System Exam (Q&A) (January 1998)

January 1998 page 10 Coding Consultation Documentation Guidelines, Comprehensive Level/Single Organ System Exam (Q&A) Question The instructions for comprehensive level/single organ system exams state: Perform all elements identified by a bullet; document every element in a shaded box and at least one element in an unshaded box. Does "a" element mean one element or every element? AMA Comment In a comprehensive general multi-system examination, a physician needs to document at least two elements identified by a bullet and perform all elements. Documentation Guidelines, Comprehensive Level/Single Organ System Exam (Q&A). CPT® Assistant. 1998; January 1998 page 10 ...

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