Results 1 to 3 of 3

Derm e&m

  1. #1
    South Salt Lake
    Default Derm e&m
    Medical Coding Books
    I have just started coding for Derm, my doc and I are in discussion concerning his E&M levels with regards to the exam portion. I know for 1995 guidelines it would be 4 areas checked.

    Someone please help me with the 1997 skin exam, because there is a note under the "Skin box" that states " For the comprehensive level, the examination of all 4 anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately". So what level of exam would you get for the following note for 1997 guidelines? I would appreciate any help at all!

    General Examination:
    GENERAL APPEARANCE: healthy appearing, pleasant, NAD.
    NEUROLOGIC: alert and oriented.
    PSYCH: mood/affect appropriate.
    SCALP: AK's.
    FACE: within normal limits.
    EYELIDS: within normal limits.
    LIPS: within normal limits.
    NECK: within normal limits.
    CHEST: within normal limits.
    ABDOMEN: within normal limits.
    BACK: dark macule 5 cm L of T12.
    R UPPER EXTREMITY within normal limits.
    R HAND/FINGERS within normal limits.
    L UPPER EXTREMITY L proximal third forearm keratotic papule, AK's .
    L HAND/FINGERS within normal limits.
    L LOWER EXTREMITY within normal limits.
    R LOWER EXTREMITY within normal limits.

  2. #2
    In dermatology, you are not likely to EVER get a comprehensive, because it involves examination of organ systems that don't concern dermatology.

    The points you can get for a derm exam in the 1997 guidelines - one point for each item on the list - are:

    SKIN OF:
    head and/or face
    conjunctivae and/or eyelids
    lips, gums, and/or teeth
    genitalia, groin, and/or buttocks
    R upper extremity
    L upper extremity
    R lower extremity
    L lower extremity

    digits and/or nails
    sweat glands
    vascular system
    liver and spleen
    lymph nodes

    If you can check 12 items on that list*, you get a detailed exam. 6-11 gets an expanded problem-focused exam. 1-5 is problem-focused.

    *This is assuming two things: That it was medically necessary to examine each of these areas (given the patient's complaint), and that you have subtracted from the list any areas that were examined as part of an office procedure the same day.

  3. #3
    South Salt Lake
    Thanks again!

Similar Threads

  1. Derm biopsy
    By beedilla80 in forum Dermatology
    Replies: 7
    Last Post: 08-07-2015, 01:17 PM
  2. Derm coding 11300-11303 & 11305-11308
    By barrier in forum Dermatology
    Replies: 4
    Last Post: 08-29-2012, 02:36 PM
  3. Derm exam
    By cyrucats in forum Dermatology
    Replies: 1
    Last Post: 11-10-2010, 03:24 PM
  4. New to Derm; HELP!
    By reichtina320 in forum Dermatology
    Replies: 7
    Last Post: 07-28-2008, 03:50 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.