AMA CPT® Assistant - 1998 Issue 1 (January)

Documentation Guidelines, Performing Additional Elements (Q&A) (January 1998)

January 1998 page 10b Coding Consultation Documentation Guidelines, Performing Additional Elements (Q&A) Do you realize that several exams are flawed by leaving out certain critical elements, such as checking the eyes for evidence of damage from hypertension in a genitourinary exam? AMA Comment The content of the examinations was determined only after consultation with the national medical specialty societies whose members provide those exams. If you perform additional elements, they should be documented in the record. Documentation Guidelines, Performing Additional Elements (Q&A). CPT® Assistant. 1998; January 1998 page 10b ...

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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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