Reader Question: Look To CPT For Advice When Patient History Is Unobtainable

Article Overview

This Find-A-Code article addresses a CPT documentation question involving a patient who cannot communicate and the effect that has on history reporting for evaluation and management services. It also covers the relationship between a procedure service and separately reported hospital care, including the need to distinguish the services in the record. The article is aimed at coders, auditors, and clinicians who need to understand the general CPT guidance discussed in this scenario.