AMA CPT® Assistant - 2023 Issue 4 (April)

Questions and Answers (April 2023)

April 2023 page 23 Questions and Answers Evaluation and Management: Evaluation and Management (E/M) Services Guidelines Question: If a pediatric patient is unable to provide their medical history because of their developmental stage and/or age, does the parent or guardian who then provides the history count as an independent historian? The definition of an independent historian states that the individual must provide a history in addition to a history provided by the patient. Therefore, does a parent providing history for a newborn fulfill the “in addition to” requirement to count or qualify as an independent historian? Answer: Yes, the...

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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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