Dermatology Coding Alert

Published on Thu Aug 18, 2005 PDF

Question: A patient came in thinking she had a thorn stuck in her hand. The dermatologist scraped a blade across her hand but did not find anything. Of course, with the scraping, the surface layers of skin were removed. Is there a CPT code for this procedure?

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Answer: In this case, there is probably not a CPT code. Report this visit with the appropriate evaluation and management code. If the dermatologist found a foreign body, you could report 10120 (Incision and removal of foreign body, subcutaneous tissues; simple).
 
Watch for: You should avoid the practice of assigning a "standard" E/M level (for instance, 99213 for an established patient) for all E/M services. Look at the physician's documentation and determine the extent of the history, exam and medical decision-making (MDM). For new patient office visits (99201-99205) and consults 99241-99255, you must base the E/M level on all three key components (history, exam and MDM). For established patient visits (99211-99215) and consults 99261-99263, you need to match only two of the three key components to choose an E/M level.