Wiki Risk factor for Skin Biopsy

[SUN1633]

Hi,
We are having a debate in our office regarding choosing the Risk Factor for Skin Biopsies. When looking at the RISK table, skin biopsy is found under the Low Risk column. Others are looking to the Moderate risk column, under "Undiagnosed new problem with uncertain prognosis e.g. lump in the breast".


For example, Let's say it is an established patient with a Detailed HPI, EPF exam, with 2 established improved diagnosis with no treatment, and a biopsy of arm to rule out isk-vs bcc.

What risk factor do you chose?

Thank you in advance!

 

[thomas7331]

It's important to keep in mind that the risk table is only meant to be a guide. Per the CMS guidelines: "Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment."

Based on the above, I think that low risk is the most appropriate risk assignment for most skin biopsies in the absence of additional documentation of risk (e.g. documentation that suggests the provider may be investigating something that is potentially more serious than isk vs bcc, or there are additional comorbidities that the provider has indicated would increase the patient's level of risk with this problem.) ISKs and BCCs are manageable problems and in most cases not a serious risk to life or limb, and certainly not before the next encounter, so unless a provider specifically stated that the lesion was suspicious for melanoma or other factors, I don't think it warrants being classified as a 'new problem with uncertain prognosis'.

 

[ellzeycoding]

The risk factor has to do with the patient not the procedure. It's not that one procedure is riskier than the other.

The patient has risk factors that may require more advanced decision making

For example... the patient has a bleeding disorder. The the patient has difficulty healing... the patient has allergies to anesthesia, or chemicals used during the procedure.

These risk factors should be documented in the encounter for the procedure.

Also remember that minor procedures include the E/M that leads to the decision to perform them. So when calculating the E/M you can't count the risk factor for the procedure (if it's a minor procedure), because that's part of the procedure. The E/M is based on a separately identifiable matter (not the biopsy in your case).