Wiki Derm exam

[cyrucats]

Derm coders, my physician has a new statement he is using. Instead of naming all the body parts he has examined, he is now stating "I have done a full skin examination today and have found no other areas of frank melanoma”. I cannot figure out where he comes up with something like this. How many bullets would you give for this statement? I need some backup before I go back to him on this.

Thanks.

Cyndi

 

[FTessaBartels]

1997 Skin exam

The following is PART of the exam under the 1997 specialty exam for skin

Inspection and/or palpation of skin and subcutaneous tissue (e.g. rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following ten areas:
* Head, including the face and
* Neck
* Chest, including breasts and axillae
* Abdomen
* Genitalia, groin, buttocks
* Back
* Right upper extremity
* Left upper extremity
* Right lower extremity
* Left lower extremity

If you physician has stated he "did a full examination of the skin" then I'd give him credit for the above bullets.

Of course, that is only going to help you if you are using the 1997 special exam guidelines for auditing the entire note.

Hope that helps.

F Tessa Bartels, CPC, CEMC