AMA CPT® Assistant - 2025 Issue 12 (December)
Questions and Answers
December 2025 pages 26-32 Questions and Answers Evaluation and Management (E/M): Services Guidelines Question: An established patient being treated for obesity presents for a follow-up weight-loss check. The nurse notes that the patient continues to lose weight but has not reached her final weight-loss goal. Would the complexity of problems addressed be considered low-level medical decision making (MDM) for a stable condition because she is losing weight and making progress toward her short-term goals, or moderate-level MDM with exacerbation/progression because she has not reached her final weight-loss goal? Answer: For a nursing visit, code 99211, Office or other outpatient...
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Article Overview
This Q&A article addresses a range of coding questions spanning office E/M, telemedicine, respiratory surgery, nervous system surgery, eye procedures, diagnostic radiology, and ophthalmology. It is intended for coders, billers, compliance staff, and clinical documentation teams who need to compare encounter details with current CPT guidance and related reporting conventions. The article provides general guidance on code selection, service classification, modifier use, and how certain procedures are reported in common specialty scenarios.
Why This Topic Matters
It helps readers recognize how current coding guidance applies across multiple specialties and service types, especially when documentation, timing, laterality, procedure overlap, or modality changes can affect reporting.
Article Sections
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December 2025 pages 26-32
Publication header indicating the date and page span for this Q&A compilation.
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Evaluation and Management (E/M): Services Guidelines
Questions and answers about office/visit classification, follow-up care, and related E/M considerations.
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E/M: Telemedicine Services
Guidance on telemedicine reporting, related prior encounters, and encounter interruption scenarios under CPT 2025 telemedicine guidance.
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Surgery: Respiratory System
A surgical coding question involving nasal procedures and the reporting of epistaxis-related care.
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Surgery: Nervous System
Questions on spinal surgery coding, modifiers, fascial plane blocks, cryoablation, and related procedure reporting issues.
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Surgery: Eye and Ocular Adnexa
A question about coding removal of an implanted ocular device without reimplantation.
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Radiology: Diagnostic Radiology (Diagnostic Imaging)
Questions addressing MRI safety implant assessment reporting and time-based code use.
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Medicine: Ophthalmology
A question about reporting a diagnostic dark adaptation examination when performed for one or both eyes.
What You Will Learn
- How this Q&A article is organized across several CPT specialty sections
- Which topics in E/M and telemedicine are addressed by the article
- What kinds of surgery, radiology, and ophthalmology reporting questions are covered
- How the article frames documentation and timing issues in coding guidance
- Where the article discusses modifier use, add-on reporting, and encounter-based considerations
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Compliance personnel
- Physician and clinic documentation teams
- Practice managers
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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