AMA CPT® Assistant - 2021 Issue 7 (July)
Frequently Asked Questions (July 2021)
July 2021 page 8 Frequently Asked Questions Evaluation and Management (E/M): Office or Other Outpatient Services Question: A patient is seen by a physician or other qualified health care professional (QHP) in a cardiology clinic where recent laboratory results (not billed by the clinic or physician) are documented or reviewed and counted as data elements for determining the E/M level of medical decision making (MDM) for all E/M office codes (99202-99205, 99212-99215). The patient returns a month later and is seen by a different physician in the same specialty and clinic. May this second physician count data elements for...
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Article Overview
This July 2021 FAQ article from CPT Assistant addresses a mix of evaluation and management and procedure-coding questions for office/outpatient E/M, surgery, medicine, psychiatry, cardiology, and infusion services. It focuses on how the guidance applies to common documentation and reporting scenarios, including laboratory review, point-of-care testing, congenital echocardiography, hydration services, and selected surgical procedures. The article is useful for coders, billers, auditors, and clinicians who need a broad view of CPT-related questions discussed in the issue.
Why This Topic Matters
It helps readers understand where CPT Assistant has clarified reporting concepts across several specialties and service types, which can affect claim accuracy and documentation review. It is especially relevant for practices that code E/M services, cardiology imaging, surgical procedures, psychiatry services, or infusion/hydration services.
Article Sections
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Evaluation and Management (E/M): Office or Other Outpatient Services
Questions in this section address office or outpatient E/M documentation and data review concepts. The discussion spans laboratory results, point-of-care testing, psychometric and physiologic data, and related CPT 2021 guidance.
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Surgery: Integumentary System
This section covers a reconstructive breast surgery scenario and reporting considerations for related operative services. It focuses on surgical procedure selection within the integumentary system.
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Surgery: Respiratory System
This section addresses a respiratory system procedure question involving an airway-related service and anesthesia reporting. It discusses how the service is considered in relation to anesthesia coding.
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Surgery: Urinary System
This section discusses a urinary system procedure and the handling of parenthetical procedures listed with a CPT code. It focuses on reporting considerations for prostate-related surgery.
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Surgery: Nervous System
This section covers implantation of a deep brain stimulator generator for epilepsy. It addresses code selection within nervous system procedures.
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Medicine: Psychiatry
This section addresses psychotherapy provided in conjunction with an E/M service. It discusses time-based reporting considerations in psychiatric medicine.
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Medicine: Cardiovascular
This section concerns echocardiography coding for congenital cardiac anomalies. It discusses how congenital and noncongenital echocardiography services are distinguished in the guidance.
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Medicine: Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration
This section covers hydration infusion reporting in the setting of prolonged IV therapy. It addresses supervision requirements and the relationship to hydration service reporting.
What You Will Learn
- How the article organizes FAQ guidance across E/M, surgery, and medicine sections.
- Which broad CPT coding topics are discussed in the July 2021 issue.
- How the article frames common documentation and reporting scenarios for selected specialties.
- What categories of CPT guidance are addressed for laboratory review, imaging, psychotherapy, and infusion services.
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Physicians and qualified health care professionals
- Revenue cycle teams
- Clinical documentation specialists
Codes Discussed
Code Ranges Discussed
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