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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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This April 2023 Q&A article addresses several CPT coding topics across multiple specialties, including evaluation and management, emergency department services, integumentary surgery, musculoskeletal surgery, digestive system surgery, and pulmonary diagnostic testing and therapies. It is intended for coders, billers, and compliance staff who need to understand the scope of the guidance and the code families discussed before reviewing the full article.

Why This Topic Matters

The article helps readers identify whether the discussion is relevant to their coding workflow by summarizing the service areas and the kinds of CPT guidance addressed. It is especially useful when a question involves documentation, code selection, unlisted procedures, or modifier usage within a 2023 CPT context.

Article Sections

  1. Evaluation and Management: Evaluation and Management (E/M) Services Guidelines

    Questions and answers addressing E/M guideline concepts and the role of supporting history from other sources.

  2. Evaluation and Management: Emergency Department Services

    Questions and answers addressing emergency department documentation review and related CPT medical decision-making concepts.

  3. Surgery: Integumentary System

    Questions and answers addressing surgical coding topics within integumentary procedures, including procedure reporting, repair groupings, and use of related modifiers and unlisted codes.

  4. Surgery: Musculoskeletal System

    Questions and answers addressing musculoskeletal CPT reporting issues, including deleted codes, unlisted procedures, and facial prosthesis-related services.

  5. Surgery: Digestive System

    Questions and answers addressing hernia repair coding topics, including procedure selection and modifier use in abdominal hernia cases.

  6. Medicine: Pulmonary Diagnostic Testing, Rehabilitation, and Therapies

    Questions and answers addressing pulmonary therapy reporting, unlisted services, and payer-related documentation considerations.

What You Will Learn

  • The scope of CPT Q&A guidance covered in this April 2023 article
  • Which specialty sections the article discusses
  • The general types of documentation and reporting issues addressed
  • Where the article touches on unlisted procedures and modifiers
  • How the article is organized across E/M, surgery, and medicine topics

Who Should Read This

  • Medical coders
  • Coding auditors
  • Billing staff
  • Compliance professionals
  • Revenue cycle teams
  • Healthcare providers involved in documentation

Codes Discussed

Code Ranges Discussed

Modifiers Discussed


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