AMA CPT® Assistant - 2022 Issue 2 (February)
Questions and Answers (February 2022)
February 2022 page 13 Questions and Answers Evaluation and Management (E/M): Office or Other Outpatient Services Question: What are the Current Procedural Terminology (CPT®) guidelines for reporting E/M codes (99202-99205, 99212-99215) when information regarding problems addressed at a previous visit is copied and pasted into the current visit’s electronic health record (EHR)? This is especially concerning when there are no changes to the EHR or the treatment plan, as it is not clear whether the physician or other qualified health care professional (QHP) addressed the condition. Should it be expected that the physician or other QHP would update...
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Article Overview
This February 2022 CPT Assistant Q&A article covers a range of coding and documentation topics across multiple specialties, including office or other outpatient evaluation and management, surgical procedures, radiology, and pathology/laboratory reporting. It is useful for coders, auditors, and billing staff who need to understand how CPT guidance applies to common reporting scenarios, related modifiers, and interactions with payer edits or global package concepts.
Why This Topic Matters
The article helps readers recognize when CPT reporting questions arise in everyday practice and where official guidance addresses documentation, procedure selection, modifier use, and related coding considerations across several service categories.
Article Sections
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Evaluation and Management (E/M): Office or Other Outpatient Services
Questions and answers on office and outpatient E/M documentation and reporting topics. The section addresses how CPT guidance relates to encounter documentation, shared MDM concepts, and related service elements.
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Surgery: Integumentary System
Questions and answers concerning surgical reporting within the integumentary system and related procedure relationships. The section focuses on when certain procedures may be reported together and on code-set boundaries.
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Surgery: Musculoskeletal System
Questions and answers about musculoskeletal surgical coding issues. The section includes topics related to procedure reporting, add-on code wording, and minimally invasive joint-related services.
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Surgery: Urinary System
Questions and answers addressing urinary system procedure reporting scenarios. The section discusses combined service reporting and modifier use in the context of stone treatment.
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Surgery: Maternity Care and Delivery
Questions and answers involving obstetric global packages, postpartum care, and related reporting considerations. The section also addresses how services may be divided among groups and the impact on separate reporting.
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Radiology: Bone/Joint Studies
Questions and answers on musculoskeletal imaging reporting and related claim edits. The section covers separate studies, documentation expectations, and Medicare-specific edit considerations.
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Pathology and Laboratory: Immunology
Questions and answers about immunology laboratory reporting. The section focuses on antibody testing, methodology references, and component reporting considerations.
What You Will Learn
- How CPT Assistant addresses documentation concerns in office and outpatient E/M reporting
- How procedure relationships and code-set boundaries affect surgical reporting
- How obstetric global package concepts affect postpartum service reporting
- How imaging studies may be reported when separate examinations are performed
- How laboratory test reporting may vary by methodology and professional component issues
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Physician practices
- Compliance professionals
- Revenue cycle teams
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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