HPI Questions

ahuffine

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Need assistance: How would you code:

CC/HPI: Pt is a 34-year-old male who presents as a new pt for a complete skin exam with concerns regarding a "mole" on the right lower back. He is unsure how long it has been present, but notes it looks different than it used to. It is asymptomatic and has not been treated previously.

Health history: Skin history: >3 blistering sunburns or tanning bed use, abnormal moles. Medical history: Asthma, eye or vision problems. NKDA. Social history: Domestic partner, hobbies include climbing & astronomy, Grew up in Eugene, OR, never a smoker and never drinks alcohol.

Skin problem list: No relevant skin disease history.

ROS: No additional skin complaints, no constitutional symptoms.

General exam: Patient appears well developed, well nourished, in no apparent distress and appears stated age. Examination found to be normal (except as noted below in skin exam): Scalp and body hair, Head (including the face), Neck, Chest (incl. breasts/axillae), Abdomen, Buttocks, Back, Right upper extremity, Left upper extremity, Right lower extremity, Left lower extremity, Digits/Nails, Eyes/Eyelids and ENT (lips).
Skin Exam: trunk; extremities - uniformly pigmented, symmetrically shaped or phenotypically consistent macules/papules; right dorsal hand - uniformly pigmented, symmetrically shaped macule/papule; lower back - including right lower back - scattered skin-colored-brown 'stuck on' verrucous papules/plaques; right lateral mid back - asymmetrically pigmented lesion with irregular border.

Assessment & Plan: Problem 1. Nevi, benign (trunk; extremities) Pt reassured. Problem 2. Nevus, benign (right dorsal hand) Pt reassured. Problem 3. Seborrheic Keratoses (lower back - including right lower back) Pt reassured. Problem 4. Neoplasm of Uncertain Behavior - r/o MM (right lateral mid back) - Diff dx: nevus vs MM. Procedure: Biopsy, tangential.
 
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snjberry

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I would code this a 99202 heres why.
History of present illness is Brief in nature with 2 elements documented clearly. Pertinent ROS to problem should say more of provider findings. and answer questions of pain, duration, what helps or hurts etc. but doesn't
for history / ROS I would limit visit to EPF which is level 99202 for a newpt
Exam is seems to be complex and would allow for 99205
Complexity of MDM seems to be moderate. benign issues for 2 diagnosis with no further tx and 1 diagnosis for minor surgical intervention. 4 overall diagnosis this would allow for 99204

Per guidelines put codes in order 99202, 99204, 99205 and choose lowest code which is 99202

Hope this helps and would welcome another opinion.

Sandi B CPC, CPMA
 

ahuffine

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So you would do 99202 adding a -25 even though the provider did a biopsy? We have struggled with new pt visits and procedures, especially when, like in this case, the procedure is being done on what the pt is complaining about.
 
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