AMA CPT® Assistant - 1998 Issue 1 (January)

Documentation Guidelines, Unshaded, Non-bulleted Elements (Q&A) (January 1998)

January 1998 page 10a Coding Consultation Documentation Guidelines, Unshaded, Non-bulleted Elements (Q&A) When it says to document every element in an unshaded box, does that include the unshaded body areas that have no elements identified by a bullet? AMA Comment No. If there are no elements in an unshaded box, whether it identifies a body area or organ system, nothing needs to be documented. If there is a pertinent finding in one of these areas, of course, for good patient care, it should be noted. Documentation Guidelines, Unshaded, Non-bulleted Elements (Q&A). CPT® Assistant. 1998; January 1998 page...

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