Dermatology Coding Alert

Published on Sat Sep 11, 2004 PDF

Here's a template to help you master E/M coding for necessary skin procedures 

If your dermatologist performs cosmetic procedures and medically necessary services on the same date, you can select the appropriate E/M code every time if you follow one simple template.

Templates Don't Require Clinical Knowledge

Here's an example of when a physician's lack of E/M documentation details can cause problems for your coding: A patient comes to your practice regularly for cosmetic Botox injections on her face. One visit, the patient complained of an irritated, scaly patch of skin on her elbow. To find the cause of the irritation, the physician performed a complete exam and determined that the cause of the eczema was the patient's medication (692.3, Eczema; due to drugs and medicines in contact with the skin).

With careful documentation of the additional time and effort it took the physician to investigate the cause of the eczema, you can rate a higher-level code for the phys-ician's extensive work to determine the patient's condition.
In this instance, the physician performed an expanded problem-focused history. With the use of a template, the physician could make sure his documentation showed that he examined the patient's extremities, back and chest for other patches of eczema, in addition to the face and elbow.  The nurse also measured the patient's blood pressure, pulse, respirations and temperature. The physician's medical decision to diagnose eczema only required low complexity. Therefore, you should report E/M code 99213 (Office or other outpatient visit for evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity ...).

If the physician had not used the template to document the more extensive exam, you could only report 99212 (Office or other outpatient visit for evaluation and management of an established patient, which requires at least two of these three key components: a problem- focused history; a problem-focused examination; straightforward medical decision-making ...) because the documentation would include details of his examination of only two areas of the patient.
 
Advice: Use a template to collect the elements of physical history, exam, and medical decision-making the physician must meet, and to prompt the physician to complete or to provide missing documentation.
For example, in the scenario above, while taking a history of past illness, the physician uses the template to ensure he has provided a description of the skin condition and other details, such as the duration of the symptoms.

The Centers for Medicare & Medicaid Services (CMS) provides you with these templates so you can make sure your physician's documentation is pristine, which will help you select the right code, avoid denials and make it through any audit (internal or external), says Linda Martien, CPC, CPC-H, coding consultant at National Healthcare Review Inc. in Woodland Hills, Calif.
 
Customized Templates Require Specialty Details

Many practices may already use off-the-shelf CMS template charts successfully, but you can also customize your own template. You can even shrink down your template and place it on index cards in your exam rooms, if it helps your dermatologists to use the template, says Lisa Center, CPC, quality coordinator with Freeman Health System in Joplin, Mo.

Warning: Don't underestimate what to include in your customized template, because you have to cover ALL the necessary details to make your own template viable.

Tip: Examine your customized templates closely to make sure they provide the information that is unique to your practice and coding requirements.

Check the types of specialty-specific, "related procedure" information the template should include. For example, make sure your dermatology template includes inspection and/or palpation of skin and subcutaneous tissue and general appearance of the patient. If the template lacks this information, the documentation will as well, coding experts say.