CPT Knowledgebase - Feb 9, 2022

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 visits 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 the current note stating there are no diagnosis and treatment changes? What do coders need to see in the report in order to know whether the condition and treatment should be counted toward selecting the appropriate level of medial decision making (MDM)?

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