Wiki HISTORY OF QUESTION

[CODE.REBECCA.DEWICK]

Can anyone confirm??? With History of Skin Cancer- if you also bill for screening for malig neoplasms that would count as a "condition" toward your E/M code...... yes/no?? thoughts

Rebecca

 

[thomas7331]

You're question is confusing. A 'screening' is a preventive service done for an asymptomatic patient - that is not part of an E&M service, which is a problem-oriented service. There's no overlap between screening and E&M.

A history of skin cancer is something different entirely - that is a past resolved condition which may require ongoing monitoring or surveillance. That may be appropriate to consider toward the E&M level if it is a documented factor in the provider's services.

 

[CODE.REBECCA.DEWICK]

Im sorry, i rushed and try so hard to be clear.... YES provider documents patient has a history of-- and also documents he screened for any at time of visit noting any benign etc... i thought the combination of having a history and provider looking for any additional counted toward E/M... do you think that sounds right?

 

[thomas7331]

Im sorry, i rushed and try so hard to be clear.... YES provider documents patient has a history of-- and also documents he screened for any at time of visit noting any benign etc... i thought the combination of having a history and provider looking for any additional counted toward E/M... do you think that sounds right?

No, I wouldn't consider that as two contributing factors to MDM. Remember that MDM is about decision-making. What is the provider documenting in their assessment and plan, i.e. what problems are they considering, what risk factors are involved, and what risks are posed to the patient by the treatment options they are proposing for management of those problems? 'Screening' is not one of these - again, screening is a preventive service and isn't part of a problem-oriented E&M service because it's not directed at any symptom or disease. There's no risk to a patient in being 'checked' if there are no symptoms or problems being considered, and no 'decision' involved in conducting a screening - remember that screening is something done for a patient with no signs, symptoms or history of a particular disease.

If the provider does document benign lesions or other abnormal findings during a screening, those could be counted, because there is a decision involved there - i.e. whether to biopsy or to monitor or do nothing - and there's a risk involved in that decision. And the history of a skin cancer does involve a risk too. But a screening does not. Just my thoughts on it though - others may take it differently. These are grey areas and the guidelines can only get you so far.

 

[CODE.REBECCA.DEWICK]

No, I wouldn't consider that as two contributing factors to MDM. Remember that MDM is about decision-making. What is the provider documenting in their assessment and plan, i.e. what problems are they considering, what risk factors are involved, and what risks are posed to the patient by the treatment options they are proposing for management of those problems? 'Screening' is not one of these - again, screening is a preventive service and isn't part of a problem-oriented E&M service because it's not directed at any symptom or disease. There's no risk to a patient in being 'checked' if there are no symptoms or problems being considered, and no 'decision' involved in conducting a screening - remember that screening is something done for a patient with no signs, symptoms or history of a particular disease.

If the provider does document benign lesions or other abnormal findings during a screening, those could be counted, because there is a decision involved there - i.e. whether to biopsy or to monitor or do nothing - and there's a risk involved in that decision. And the history of a skin cancer does involve a risk too. But a screening does not. Just my thoughts on it though - others may take it differently. These are grey areas and the guidelines can only get you so far.

SO maybe i should be looking at code Z08? my provider feels he should get credit for examining skin for malignancies- if pt had a history- and is coming back at specific intervals to see if any other malig manifested.

example est pt- comes with history of melanoma and it is their scheduled bi-yearly check.... provider does a total body skin exam... since i cant count body areas to get to E/M code im now counting conditions/issues. time doesn't come into play for our picking E/M codes. Provider finds benign neoplasms. I believe we can count a 99213 E/M instead of 99212. Benign neoplasm and combination of Z08 and Z85.820 make one of the 2 self limited problems.... yes / no??

 

[thomas7331]

SO maybe i should be looking at code Z08? my provider feels he should get credit for examining skin for malignancies- if pt had a history- and is coming back at specific intervals to see if any other malig manifested.

example est pt- comes with history of melanoma and it is their scheduled bi-yearly check.... provider does a total body skin exam... since i cant count body areas to get to E/M code im now counting conditions/issues. time doesn't come into play for our picking E/M codes. Provider finds benign neoplasms. I believe we can count a 99213 E/M instead of 99212. Benign neoplasm and combination of Z08 and Z85.820 make one of the 2 self limited problems.... yes / no??

You are talking about two different things here - diagnosis coding and MDM. These are separate questions.

So first, regarding Z08 - that code is for follow-up care after a completed treatment for a neoplasm. That code would be used, for example, for a visit after a skin cancer had been removed to confirm that there was no recurrence of the lesion or other complication at the original site. That would not be the code for doing a skin exam to see if there are any new lesions or new cancers, unless perhaps there was suspicion or concern that the melanoma could have metastasized.

Regarding MDM, you are not counting diagnosis codes, you are counting problems that the provider is evaluating and treating. The history of skin cancer is a single issue as that is what is putting the patient at risk and making the visit and the skin exam medical necessary. A 'history of' is not listed as one of the types of problems in the MDM charts, but I think the closest thing there is to call this a 'stable chronic illness'. But if you want to combine it and count it with any benign lesions as two minor problems, that's fine too. Either way, together with low risk, it meets the criteria for 99213. I think you are fine assigning 99213 here for a patient with a known history of melanoma requiring a period skin check.

Don't overthink the MDM rules here - these are intended to be general guidelines for classifying a wide variety of clinical situations - you won't find a rule that will tell exactly the correct level for every single visit you code, and these new rules are intended to simplify E&M coding and documentation, not make it harder. 99213 is not a high-intensity service code and I can't imagine an auditor disputing this and telling you that a visit for a patient with this history should have been coded as 99212.