AMA CPT® Assistant - 2022 Issue 4 (April)
Questions and Answers (April 2022)
April 2022 page 12 Questions and Answers Evaluation and Management (E/M): Office or Other Outpatient Services Question: What information is necessary in order to report E/M office visit codes based on time, rather than medical decision making (MDM)? Answer: Total time on the date of the encounter must be documented when time is used as the basis for Current Procedural Terminology (CPT®) E/M code selection, including both the face-to-face and non–face-to-face time personally spent by the physician and/or other qualified healthcare professional (QHP). It includes time performing activities that require the physician or other QHP; however, it does...
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Article Overview
This article summarizes multiple April 2022 CPT Assistant questions and answers addressing a range of current coding topics. It discusses documentation and time-based reporting for office/outpatient E/M services, preventive medicine counseling in the context of an E/M visit, procedure coding issues in musculoskeletal and respiratory surgery, cardiovascular and congenital heart catheterization reporting, laboratory testing, and post-implant audiology services. The article is useful for coders, billers, and compliance staff who need a broad overview of CPT guidance and related payer considerations.
Why This Topic Matters
It helps coding professionals understand how CPT Assistant addresses common documentation and reporting questions across several specialties, including where payer guidance may differ from CPT guidance.
Article Sections
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Questions and Answers
General introductory material for the April 2022 Q&A collection and its coding focus.
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Evaluation and Management (E/M): Office or Other Outpatient Services
Questions and answers related to office and outpatient E/M reporting, including time-based selection and MDM-related topics.
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E/M: Preventive Medicine Services
Guidance concerning preventive medicine counseling services reported in conjunction with an outpatient visit.
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Surgery: Musculoskeletal System
A coding question involving a spine-related orthopedic procedure and related reporting considerations.
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Surgery: Respiratory System
A respiratory surgery question involving laryngoscopy and supraglottoplasty-related reporting options.
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Surgery: Cardiovascular System
A cardiovascular surgery question addressing cerebral embolic protection device reporting with valve procedures.
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Pathology and Laboratory: Chemistry
Questions about laboratory chemistry reporting for testing related to heavy metals and assay type.
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Medicine: Cardiovascular
Questions covering congenital cardiac catheterization, echocardiography, and related cardiovascular diagnostic reporting.
What You Will Learn
- How CPT Assistant addresses time-based office and outpatient E/M documentation topics.
- How preventive medicine counseling may be discussed in relation to a problem-oriented E/M visit.
- How selected surgery, pathology/lab, and cardiovascular questions are handled in the April 2022 Q&A.
- How the article frames coding issues involving congenital heart disease, implanted devices, and audiology follow-up services.
- How payer guidance and CPT guidance may differ in reporting decisions.
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Compliance professionals
- Physician practices
- Hospital outpatient coding teams
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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