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...

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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

  1. Question

    Presents the coding scenario involving patient-completed low back pain assessment questionnaires and asks how they fit into reporting pathways.

  2. 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

Who Should Read This

  • Medical coders
  • Billing specialists
  • Compliance staff
  • Health information management professionals
  • Therapists and practice administrators

Codes Discussed

Code Ranges Discussed


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