mdeanne
New
Patient came in for E/M to discuss treatment options for numerous skin cancers Non-melanoma Skin Cancers (NMSCs) several biopsy proven. Came to office to discuss treatment options. Physician removed several via C & D as well as biopsy a lesion on jaw and treated some AKs.
CC/HPI:
A former patient not seen since 2007 here with h/o multiple NMSCs, most recently BCC, nodular and ulcerated and type L anterior cheek, BCC nodular type L Posterior cheek, SCCIS inferior cheek, superficial SCC L neck and SCCIS L anterior shoulder, all biopsy proven by Dr. XXXX at XYZ University Hospital on 6/21/16. Would like to discuss pathology and treatment options. Has not noted a lesion on R jaw.
ROS:
No additional skin complaints
No constitutional complaints
Exam: Patient appears well developed, nourished, in no apparent distress and appears stated age, Examination: Scalp and body hair, head, neck, chest, abdomen, buttocks, back, R arm, L arm, R leg, L leg, nails, digits, eyelids, lips.
Physician C&D-ed 3 bx proven BCC on cheeks, a SCC on shoulder, a biopsy on R Jaw, Cryosurgery on AK x 3 on temple.
He also diagnosed Hx of NMSC and Lentigines and counseled to return to clinic if any change or look suspicious. Sun avoidance and sun-protection discussed and recommended.
Here is what physician wants to bill:
99203-25
11100-XS
17000-XS
17003 x3 -XS
17281
17281-59-76
17281-59-76
17262-XS
Since the CC and HPI were all about the bx proven lesions and pt wanted treatment plan and physician actually treated (C&D) during that session, can physician still charge E/M and use 25 based on this to support a separate E/M?? If so, can it support a 99203???
A second look and input appreciated.
Melissa D.
CPC-D
CC/HPI:
A former patient not seen since 2007 here with h/o multiple NMSCs, most recently BCC, nodular and ulcerated and type L anterior cheek, BCC nodular type L Posterior cheek, SCCIS inferior cheek, superficial SCC L neck and SCCIS L anterior shoulder, all biopsy proven by Dr. XXXX at XYZ University Hospital on 6/21/16. Would like to discuss pathology and treatment options. Has not noted a lesion on R jaw.
ROS:
No additional skin complaints
No constitutional complaints
Exam: Patient appears well developed, nourished, in no apparent distress and appears stated age, Examination: Scalp and body hair, head, neck, chest, abdomen, buttocks, back, R arm, L arm, R leg, L leg, nails, digits, eyelids, lips.
Physician C&D-ed 3 bx proven BCC on cheeks, a SCC on shoulder, a biopsy on R Jaw, Cryosurgery on AK x 3 on temple.
He also diagnosed Hx of NMSC and Lentigines and counseled to return to clinic if any change or look suspicious. Sun avoidance and sun-protection discussed and recommended.
Here is what physician wants to bill:
99203-25
11100-XS
17000-XS
17003 x3 -XS
17281
17281-59-76
17281-59-76
17262-XS
Since the CC and HPI were all about the bx proven lesions and pt wanted treatment plan and physician actually treated (C&D) during that session, can physician still charge E/M and use 25 based on this to support a separate E/M?? If so, can it support a 99203???
A second look and input appreciated.
Melissa D.
CPC-D