||||||||||| XI How to Use This Manual Step 1. Use either the Table of Contents or Index to locate informa- tion on specific services, codes, or broader subjects. Contents An Introduction to the Official Code Sets 5 Telling the Encounter Story 5 Step 2. Use chapter content to review code descriptors and instructions for reporting. Before reporting, verify current codes and complete selection and reporting instructions in the appropriate code set manual or application. 99464 Attendance at delivery (when requested by the delivering physician or other qualified health care professional) and initial stabilization of newborn Code 99464 is not reported when hospital-mandated attendance is the only underlying basis for providing the service. Step 3. Examples are used as guidance on meeting the criteria specified by codes and reporting instructions. However, note that codes must be assigned based on the service provided and sup- porting documentation. The pediatrician administers 3 injections of allergen extract for a patient with allergic rhinitis due to pol- len. The extract was prepared and supplied by an allergist. The pediatrician will report code 95117 with ICD- 10-CM code J30.1. Step 4. Note key points of information highlighted in each chapter. If the physician performs the venipuncture as a convenience or because staff is not trained in the procedure, code 36415 is reported because the physician’s skill was not required. Step 5. Resources for additional information are listed at the end of each chapter as well as online at www.aap.org/cfp. CHAPTER 7. OFFICE AND OTHER OUTPATIENT EVALUATION AND MANAGEMENT SERVICES ||||||||||| 177 Chapter 7. Office and Other Outpatient Evaluation and Management Services CPT copyright 2020 American Medical Association. All rights reserved. =New code ▲=Revised code #=Re-sequenced code +=Add-on code Resources Documentation American Academy of Pediatrics Initial History Questionnaire Documentation Form for office or outpatient visits (available for purchase at http://shop.aap.org) Examples of Office E/M Code Levels “Office E/M 2021: Level 2 Visits” (August 2020 AAP Pediatric Coding Newsletter™) (https://coding.solutions.aap.org/article. aspx?articleid=2765198 subscription required) “Office E/M 2021: Level 3 Visits” (September 2020 AAP Pediatric Coding Newsletter) (https://coding.solutions.aap.org/article. aspx?articleid=2765216 subscription required) “Office E/M 2021: Level 4 Visits” (October 2020 AAP Pediatric Coding Newsletter) (https://coding.aap.org subscription required) “Office E/M 2021: Requirements, Examples, and Use of the Prolonged Service Code” (November 2020 AAP Pediatric Coding Newsletter) (https://coding.aap.org subscription required) Medical Decision-making “Office E/M 2021: An Overview of Medical Decision-making” (February 2020 AAP Pediatric Coding Newsletter) (https://coding.solutions. aap.org/article.aspx?articleid=2759684 subscription required) “Office E/M 2021: Determining the Number and Complexity of Problems Addressed” (April 2020 AAP Pediatric Coding Newsletter) (https://coding.solutions.aap.org/article.aspx?articleid=2763373 subscription required) “Office E/M 2021: Determining Levels of Amount and/or Complexity of Data” (May 2020 AAP Pediatric Coding Newsletter) (https://coding.solutions.aap.org/article.aspx?articleid=2765177 subscription required) “Office E/M 2021: Determining the Level of Risk” (June 2020 AAP Pediatric Coding Newsletter) (https://coding.solutions.aap.org/article. aspx?articleid=2765184 subscription required) “Office E/M 2021: Determining the Level of Medical Decision-making” (July 2020 AAP Pediatric Coding Newsletter) (https://coding. solutions.aap.org/article.aspx?articleid=2765191 subscription required) Overview of Office E/M Changes “Office E/M 2021: The Why and How of Changes to Office and Other Outpatient Evaluation and Management Services” (January 2020 AAP Pediatric Coding Newsletter) (https://coding.solutions.aap.org/article.aspx?articleid=2758025 subscription required) “Questions and Answers and Tips for Adopting the New Coding Guidelines” (December 2020 AAP Pediatric Coding Newsletter) (https:// coding.aap.org subscription required) Time-Based Code Selection for Office E/M “Office E/M 2021: An Overview of Time-Based Code Selection” (March 2020 AAP Pediatric Coding Newsletter) (https://coding.solutions. aap.org/article.aspx?articleid=2761969 subscription required) Prolonged Services in Conjunction With Office Visits “Office E/M 2021: An Overview of Time-Based Code Selection” (March 2020 AAP Pediatric Coding Newsletter) (https://coding.solutions. aap.org/article.aspx?articleid=2761969 subscription required) Step 6. While every effort is made to provide accurate and up-to- date coding guidance, changes do happen. Any corrections and code or instruction changes published subsequent to the date of this printing are posted online at www.aap.org/cfp. Coding_2021.indb 11 Coding_2021.indb 11 9/15/20 2:23 PM 9/15/20 2:23 PM
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