October 20, 2022

Question:
My coder just told me that for Office E/M services I no longer have to document a History. This doesn’t seem right to me.

Answer:
You are wise to ask because that’s not exactly true. It is correct that the History will no longer be used to select a new patient (9920x) or established patient (9921x) visit code. However, it is expected that you will document a “medically appropriate” (per CPT™ history for each encounter.

*This response is based on the best information available as of 10/20/22