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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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article addresses CPT evaluation and management documentation questions that arise when prior visit information is copied and pasted into a current electronic health record note. It is aimed at coders, physicians, and other qualified health care professionals who need to understand what documentation should support selection of an appropriate E/M level under the 2022 CPT framework and related medical decision-making criteria.

Why This Topic Matters

Incomplete or recycled documentation can make it difficult to determine whether a condition was actually addressed during the current encounter. The article helps readers understand the kind of current-visit documentation needed to support E/M reporting and medical decision-making review.

Codes Discussed

• CPT: 99202
• CPT: 99203
• CPT: 99204
• CPT: 99205
• CPT: 99212
• CPT: 99213
• CPT: 99214
• CPT: 99215

Code Ranges Discussed

• CPT: 99202-99205
• CPT: 99212-99215

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