AMA CPT® Assistant - 2021 Issue 3 (March)
Frequently Asked Questions (March 2021)
March 2021 page 9 Frequently Asked Questions Evaluation and Management (E/M): Office or Other Outpatient Services Question: May a parent or caregiver (eg, grandparent, foster parent) be considered an independent historian when the patient is unable to provide any history due to age or cognitive ability? Answer: Yes, a parent or caregiver may be considered an independent historian. The Current Procedural Terminology (CPT®) 2021 Guidelines for Office or Other Outpatient E/M Services defines independent historian as “an individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who...
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Article Overview
This March 2021 FAQ article addresses a range of CPT coding questions across evaluation and management, surgery, radiology, and neurology/neuromuscular procedures. It is useful for coders, clinicians, auditors, and billing staff who need to understand how the guidance applies to common encounter scenarios, including reporting considerations, time calculation issues, and related documentation expectations. The article also touches on payer policy differences and references guidance from CPT, AMA, and ACR sources.
Why This Topic Matters
It helps readers quickly assess whether the full FAQ contains guidance relevant to a specific coding question or specialty area without exposing premium details. The article is especially relevant when documentation, code selection, or modifier reporting may differ from common assumptions or payer policies.
Article Sections
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March 2021 page 9
Introduces the FAQ page and the overall March 2021 content covered in this issue.
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Evaluation and Management (E/M): Office or Other Outpatient Services
Addresses office/outpatient E/M guidance, including history-related concepts and how time is accounted for in shared or overlapping service scenarios.
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Surgery: Integumentary System
Discusses surgical coding considerations for a carpal tunnel release with additional soft-tissue work and related reporting issues.
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Surgery: Musculoskeletal System
Covers a talus-related orthopedic procedure question and the use of an unlisted code when no specific CPT code is available.
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Surgery: Respiratory System
Reviews reporting questions involving bronchoscopic biopsy procedures performed during the same encounter.
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Surgery: Female Genital System
Explores hysterectomy-related coding in the setting of a laparoscopic procedure and associated surgical services.
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Surgery: Nervous System
Addresses peripheral nerve block reporting for postoperative pain management in lower-extremity surgery.
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Surgery: Eye and Ocular Adnexa
Discusses separate reporting of eyelid procedures and the use of a modifier when appropriate.
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Radiology: Diagnostic Radiology (Diagnostic Imaging)
Covers review of outside imaging studies, consultation reporting, and the relationship between imaging review and E/M data analysis.
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Medicine: Neurology and Neuromuscular Procedures
Addresses limited electromyography reporting across multiple limbs and related unit reporting considerations.
What You Will Learn
- How this FAQ article is organized across major CPT specialty sections
- Which topics are covered in office/outpatient E/M guidance
- What general surgical scenarios are discussed across multiple body systems
- What radiology and neuromuscular coding questions are included
- What types of documentation and payer-policy issues are mentioned
Who Should Read This
- Medical coders
- Clinical documentation specialists
- Billing staff
- Physicians and other providers
- Coding auditors
Codes Discussed
Modifiers Discussed
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