According to CPT guidelines, if a history and/or physical examination is medically appropriate and performed, what is true?

According to CPT guidelines, if a history and/or physical examination is medically appropriate and performed, what is true?

• A. They are included in the service
• B. They must be billed separately
• C. They are optional
• D. They are never billed

Answer: (A)

In CPT coding, the history and physical examination are bundled into the evaluation and management service. When a history and/or physical is medically appropriate and performed during an encounter, those elements help determine the level of service but are not billed as separate codes. The E/M code you choose already accounts for the work of taking history and conducting the exam, along with the medical decision making. Only in cases where a distinctly separate and independently billable service is performed would you bill separately; the H&P itself isn’t billed on its own.

In CPT coding, the history and physical examination are bundled into the evaluation and management service. When a history and/or physical is medically appropriate and performed during an encounter, those elements help determine the level of service but are not billed as separate codes. The E/M code you choose already accounts for the work of taking history and conducting the exam, along with the medical decision making. Only in cases where a distinctly separate and independently billable service is performed would you bill separately; the H&P itself isn’t billed on its own.