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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CPT® Assistant content is the official source for CPT® coding guidance. It is an instrumental tool when appealing insurance denials and validating coding to auditors. Monthly issues and an extensive archive provide comprehensive guidance on proper CPT® coding for past, present and upcoming code set releases. Archives date back to 1990 for historical use of codes, changes, rationales, coding tips and trends in the industry.

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