CPT Knowledgebase - Jun 4, 2021

When there is an undiagnosed new problem with uncertain prognosis used to determine the number and complexity of problems addressed for medical decision making (MDM) level selection for all E/M office codes (99202-99205, 99212-99215), what is the level of severity needed for the problem to be considered or used as the data element of the MDM? This can be difficult to ascertain, especially when the physician or other qualified health care professional (QHP) does not list any differential diagnoses. For example, physicians or other QHPs may document vaginal irritation or abdominal pain with laboratory or other diagnostic tests ordered without any indication of the potential diagnoses or possible problem severity in the medical record.

To view the Official AMA answer and 1000s more like this:

CPT® Knowledge Base is a compendium of real life coding questions asked by the coding community and answered by CPT® coding experts.

Over 2900 questions and authoritative answers from the CPT® professionals at the AMA. Get specific answers to challenging coding questions, and search the knowledge base of others' real world questions.

Access to this feature is available in the following products:
  • AMA's CPT® Advanced Coding Pack

demo
request yours today
 subscribe
start today
 newsletter
free subscription

Thank you for choosing Find-A-Code, please Sign In to remove ads.