Dermatology Coding Alert

Published on Tue Jul 28, 2009 PDF

Check yourself against the scenarios on page 12.

Example 1: Problem-oriented visit In a new patient, this would be a detailed history, a level-three history with only two ROS (even though many physicians obtain a complete ROS and PFSH on a new patient). This example shows only information relevant to the presenting problem.

This visit supports 99203, if it were based on the patient's history (one of the "3 of 3" key components required in a new patient visit), according to Sandy Adams-Stevens, a coding/documentation specialist with Heritage Medical Associates in Nashville, Tenn.

For an established patient, a detailed history is known as a level-four history.

Example 2: Skin check with no known problems In a new patient, this would be an expanded, leveltwo history with only two elements (although many physicians obtain a complete ROS and PFSH on new patients). This example shows only information pertinent to the reason for the patient's visit. This visit supports 99202 for a new patient if you base your coding on patient history. For an established patient, an expanded, problem-focused history is considered a level 3 history.