AMA CPT® Assistant - 2022 Issue 12 (December)
Questions and Answers (December 2022)
December 2022 pages 15-18 Questions and Answers Evaluation and Management (E/M): Office or Other Outpatient Services Question: Do the statements “laboratory tests reviewed” (not ordered during the encounter or by the provider) or “outside records reviewed” without any analysis, summary, or reference to the results of the laboratory tests qualify for data credit based on the Current Procedural Terminology (CPT®) 2021 E/M Guidelines? Answer: The CPT 2021 E/M Guidelines specify that data elements themselves (eg, glucose) may not be subject to analysis; however, they are included in the thought processes for diagnosis, evaluation, or treatment, instead. Per the...
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Article Overview
This December 2022 Q&A article reviews a range of CPT-related topics across office/outpatient E/M, advance care planning, musculoskeletal surgery, digestive surgery, female genital surgery, nervous system procedures, diagnostic ultrasound, and psychiatric services. It is useful for coding professionals who need to understand how the CPT Editorial Panel’s guidance applies to common documentation and reporting scenarios, as well as recent add-on and Category III code updates discussed in the issue.
Why This Topic Matters
The article helps readers determine whether their situation aligns with current CPT guidance before assigning codes or reporting services. It also highlights areas where documentation, service context, and code-set updates can affect reporting across multiple specialties.
Article Sections
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Questions and Answers
General CPT-related Q&A content for the December 2022 issue. The section introduces a series of specialty-specific coding scenarios and guidance topics.
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Evaluation and Management (E/M): Office or Other Outpatient Services
Guidance related to office and outpatient E/M data considerations and family-based new patient visit scenarios. The section addresses documentation and reporting questions within E/M services.
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E/M: Advance Care Planning
Discussion of advance care planning in relation to other same-day services and reporting context. The section focuses on how ACP is addressed alongside other E/M or critical care services.
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Surgery: Musculoskeletal System
Coding guidance for a musculoskeletal procedure involving spinal implant work. The section addresses procedure reporting when no specific CPT code is available.
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Surgery: Digestive System
A digestive system surgery scenario involving treatment of hemorrhoids and code selection. The section discusses reporting when the described service does not match a specific CPT description.
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Surgery: Female Genital System
Reporting guidance for a gynecologic procedure performed with sedating agents. The section covers whether separate reporting is appropriate in the described encounter.
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Surgery: Nervous System
A nerve block reporting question involving a bilateral abdominal cutaneous nerve procedure. The section explains the relevant CPT context for this anesthetic/nerve block service.
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Radiology: Diagnostic Ultrasound
Diagnostic ultrasound and quantitative tissue characterization guidance, including newer Category III code reporting. The section covers how ultrasound imaging and non-elastographic characterization are discussed together.
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Medicine: Other Psychiatric Services or Procedures
Psychiatric service documentation and referral-related reporting guidance. The section addresses a report-preparation service for use by other parties.
What You Will Learn
- How this issue addresses CPT guidance across several specialties
- Which topics are covered in office/outpatient E/M and advance care planning
- How the article frames reporting questions in surgery and radiology
- What general kinds of psychiatric service reporting questions are discussed
- How the issue references newer ultrasound-related CPT additions
Who Should Read This
- Professional coders
- Coding auditors
- Compliance staff
- Physician practices
- Hospital coding departments
- Specialty billing teams
Codes Discussed
Code Ranges Discussed
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