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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Article Overview
This short AMA Coding Consultation Q&A addresses a documentation guideline question from January 1998 related to CPT Assistant. It is aimed at coders, compliance staff, auditors, and clinicians who need a quick read on what the article covers and the type of documentation issue discussed, without replacing the full guidance.
Why This Topic Matters
It helps readers determine whether the article is relevant to documentation and coding workflows tied to AMA guidance, especially when reviewing exam-style Q&A content from CPT Assistant.
Article Sections
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Coding Consultation
Introduces the Q&A format and the documentation topic being addressed in the January 1998 article.
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AMA Comment
Presents the AMA’s response to the documentation question and the general context for the guidance discussed.
What You Will Learn
- What documentation topic the Q&A addresses
- How the article is structured as a consultation and comment format
- The general scope of the guidance discussed in this CPT Assistant item
- Whether the article is likely relevant to documentation review or coding education
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physicians and clinical documentation staff
- Coding educators
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