AMA CPT® Assistant - 2021 Issue 11 (November)
Frequently Asked Questions (November 2021)
November 2021 page 12 Frequently Asked Questions Evaluation and Management (E/M): Office or Other Outpatient Services Question: If an established patient sees a physician or other qualified health care professional (QHP) for two acute, uncomplicated and unrelated problems that are reported with E/M code 99212, may the problems addressed at the encounter be considered as moderate medical decision making (MDM) because two problems were addressed? Answer: No, two acute, uncomplicated, and unrelated problems addressed at the specified encounter would not be considered as moderate MDM. The Current Procedural Terminology (CPT®) 2021 code set defines acute, uncomplicated illness or...
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Article Overview
This article collects multiple coding questions and answers from November 2021 across several CPT subject areas, including office or other outpatient E/M, preventive medicine, surgery, diagnostic imaging, moderate sedation, and Category III procedures. It is useful for coders, billers, auditors, and clinicians who need to understand the scope of the guidance discussed and the types of scenarios addressed in the FAQ format.
Why This Topic Matters
It helps readers identify whether the article addresses the coding topic they are researching and signals that the discussion spans multiple specialties and CPT code families. The piece is relevant for professionals looking for CMS/CPT-related guidance, documentation considerations, and code-reporting issues discussed in a FAQ format.
Article Sections
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Evaluation and Management (E/M): Office or Other Outpatient Services
Questions and answers on office and outpatient E/M services, preventive medicine services, documentation, and related CPT guidance. The section also discusses general reporting considerations involving tests and separately reportable services.
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Surgery: Musculoskeletal System
A question and answer on revision total knee arthroplasty coding and modifier use within musculoskeletal surgery. The section addresses reporting considerations for component exchange scenarios.
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Surgery: Respiratory System
A question and answer about nasal/sinus endoscopic surgery and repeat reporting considerations. The section focuses on respiratory surgery coding and procedure bundling concerns.
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Surgery: Cardiovascular System
A question and answer involving pericardial procedures, chest tube placement, and related parenthetical notes in CPT. The section covers cardiovascular surgery reporting and modifier-related issues.
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Surgery: Eye and Ocular
A brief question and answer about a lower eyelid repair procedure in the eye and ocular surgery category. The section identifies the relevant CPT code family for the service.
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Radiology: Diagnostic Radiology (Diagnostic Imaging)
Questions and answers on ultrasound guidance, contrast-enhanced ultrasound, and liver biopsy coding within diagnostic radiology. The section also touches on reporting multiple imaging studies and separate documentation.
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Medicine: Moderate (Conscious) Sedation
A question and answer covering the CPT moderate sedation guidelines and intraservice time concepts. The section is centered on medicine coding and sedation service reporting.
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Category III Codes
A question and answer about a Category III ophthalmic procedure and whether an associated injection can be reported separately. The section highlights Category III coding relationships and inherent services.
What You Will Learn
- Which broad CPT subject areas are addressed in this FAQ collection.
- What general kinds of documentation and reporting questions are discussed for office/outpatient E/M.
- How the article frames separate reporting issues across surgery, radiology, medicine, and Category III procedures.
- Which code families and specialty areas are involved in the questions.
- The types of CPT Assistant guidance included in a multi-topic FAQ issue.
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Physicians and other qualified health care professionals
- Compliance staff
- Practice managers
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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