Evaluation and Management/Hospital Discharge Services (November 2009)
November 2009 page 10a
Evaluation and Management: Hospital Discharge Services, 96101, 96125 (Q&A)
Question: For patients being assessed for low back pain, some
providers administer and then assess, and may over time follow with tests, such as the
Roland-Morris Low Back Pain and Disability Questionnaire, the Oswestry Disability
Questionnaire, and similar back or spinal assessment questionnaires. Can these be
reported using codes 96101-96125, (Central Nervous System
Assessments/Tests [eg, Neuro-Cognitive, Mental Status, Speech Testing])? If not, how
should these be reported?
Answer: Tests of this type are not separately reported using
codes 96101-96125 or other CPT codes; instead, they...
Note: The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.
Article Overview
This article addresses a coding question about patient-administered back pain and disability questionnaires and explains the general category of service classification involved. It is aimed at coders and billing professionals who need to understand how these assessment tools are treated within evaluation and management documentation and reporting workflows.
Why This Topic Matters
It helps readers determine whether common patient questionnaire-based assessments should be considered separately reportable services or part of broader evaluation and management work.
Article Sections
Question
Presents the coding scenario involving patient-completed low back pain assessment questionnaires and asks how they fit into reporting pathways.
Answer
Provides a general explanation of how these assessment tools are treated in relation to evaluation and management services and therapist evaluation processes.
What You Will Learn
How the article frames patient-completed assessment questionnaires in a coding context
The general relationship between these assessments and evaluation and management services
The type of documentation and service classification issues raised by the Q&A format
Why certain assessment tools are discussed in connection with broader clinical evaluation workflows
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