Oncology & Hematology Coding Alert

Question: A patient returned for a six-month follow-up after undergoing a punch biopsy of his palate. The patient reported he was fine and experiencing no pain, discomfort, or any new symptoms. The biopsy led to a diagnosis of D10.30. I view this condition as being more serious than a self-limited or minor problem, which I was told is a condition that will resolve without medical treatment.

Because of this, can I code this as a level 3 evaluation and management (E/M) encounter?

AAPC Forum Participant

Answer: While D10.30 (Benign neoplasm of unspecified part of mouth) is undoubtedly a more serious condition than a self-limited or minor problem (defined by CPT^® as a “a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status”), the seriousness of the problem does not automatically equate to a higher level of the E/M service.

The reason for this is because “two of the three elements … must be met or exceeded” for a given level of medical decision making (MDM) per CPT^®, and the number or complexity of problems addressed at the encounter is only one of those elements. Based on the information you have provided, your provider had minimal or no data to review or analyze relating to the patient’s condition; the provider did not prescribe drugs to manage the patient’s condition; the provider made no decisions regarding surgery for the patient; and any treatment your provider is considering for the patient’s condition is not hampered by social determinants of health.

Consequently, with a straightforward level of MDM for the amount of complexity of data reviewed or analyzed, and a minimal risk of morbidity from any additional diagnostic testing or treatment, even with a low level of MDM for the patient’s condition, the overall level of MDM for this scenario only rises to straightforward at best. That means your MDM level only allows reporting 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …) based on the information provided.