Wiki Office visit charge with procedure

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Metroderm

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I would like to make it clear before I talk to the provider.

Ex) Patient came in for Acne surgery (10040) and patient said " By the way doctor, I have dry skin on my back."
Doctor took a look and advised patient to take a short shower and apply lots of moisturizer.

Doctor insists that he can charge 99213-25 because he gave pt a consult and it is a different Dx.
I said "No" because it doesn't have enough to support the charge because there is no Rx given and gave a simple remedy.

I would like to know what you all think.
Thank you.
 
Just remember that as coders, we can only make code choices based only on the documentation and not on a scenario. I would look here at the documentation of the history, exam and MDM related to the dry skin on the back and make the decision based on that alone. From what you've said, it sounds like there would at least be a problem-focused exam (one body area) and straight-forward MDM (a minor problem and minimal risk), which would qualify for 99212-25. But again, with only a scenario to go by, there's no solid way to advise on correct coding without actually seeing documentation.
 
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