AMA CPT® Assistant - 2026 Issue 9 (September)
Questions and Answers
September 2026 page 27 Questions and Answers Evaluation and Management (E/M): Service Guidelines Question: When visiting a patient in the hospital, an attending physician, who is not a hospital employee, speaks to the nurse caring for the patient to get information that the patient may be unable to provide or is not documented in the chart. Would this be considered an “independent historian” for the data element? After seeing the patient and reviewing the chart, the attending physician then discusses the care plan and any changes with the nurse. Would this be considered “discussions of care management with a...
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Article Overview
This article covers coding questions involving E/M services, several surgical specialties, diagnostic ultrasound, surgical pathology, gastroenterology, and otorhinolaryngology. It addresses general reporting and documentation considerations, including topics related to evolving technology and services introduced in 2026. The material is intended for readers who work with medical coding and clinical documentation.
Why This Topic Matters
The article brings together questions from multiple specialties, providing a scope overview for professionals seeking coding guidance on varied services and documentation topics.
Article Sections
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Evaluation and Management (E/M): Service Guidelines
This section addresses E/M data concepts in the context of hospital care and communication among members of the care team.
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E/M: Critical Care Services
This section covers questions about critical care services and other E/M services provided on the same date.
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Surgery: Musculoskeletal System
This section addresses surgical reporting questions involving upper-extremity procedures and tissue transfer.
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Surgery: Urinary System
This section discusses reporting considerations for cystostomy tube changes.
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Surgery: Female Genital System
This section addresses reporting considerations related to intrauterine device removal and insertion during a planned procedure.
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Radiology: Diagnostic Ultrasound
This section covers diagnostic ultrasound topics, including elastography and intraoperative imaging guidance.
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Pathology and Laboratory: Surgical Pathology
This section discusses surgical pathology unit-of-service questions and specimen handling.
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Medicine: Gastroenterology
This section addresses a gastroenterology service involving a sensor capsule and a coding update effective in 2026.
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Medicine: Special Otorhinolaryngologic Services
This section discusses hearing-related services for bone-conduction devices.
What You Will Learn
- Which E/M data concepts and care-team interactions are discussed.
- How the article frames questions about critical care and separate E/M services.
- What musculoskeletal, urinary, and female-genital surgical reporting topics are covered.
- Which diagnostic ultrasound and imaging-guidance scenarios are addressed.
- How specimen handling and unit-of-service questions are discussed in surgical pathology.
- What gastroenterology and hearing-device service topics appear in the article.
Who Should Read This
- Medical coders
- Coding auditors
- Physician practice and facility coding professionals
- Clinical documentation specialists
- Healthcare professionals involved in coding and billing
Codes Discussed
Code Ranges Discussed
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