Primary Care Coding Alert

Question: The physician saw an established patient with a patch of rough skin on his forearm. Using a punch tool, she took a 2-mm sample of the skin for testing and closed the site in simple interrupted fashion. (The pathology report came back as keratoderma.) During the encounter, the patient also complained of frequent headaches, and notes indicate that the physician provided a level-two E/M service to address the headaches. How should I report this encounter?

New York Subscriber
 
Answer: Because your physician performed the biopsy and the E/M service for separate problems, you can report a procedure code and an E/M code on the claim.
 
On your claim, you should submit the following:

 - 11100 (Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion) for the skin biopsy.

 - 701.1 (Keratoderma, acquired) linked to 11100 to represent the patient's rough skin.

 -  99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) for the E/M.

 -  modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached to 99212 to show that the E/M and biopsy were separate services.

 -  784.0 (Headache) linked to 99212 to represent the patient's headaches.