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Calculating E/M Code

  1. Default Calculating E/M Code
    Medical Coding Books
    Awhile ago I was informed that "personal history of skin cancer" would never net me above a 99212.

    I'm putting a ton of documents through a counter of sorts that spits out the E/M code at me. I'm feeling conflicted with what I learned and what it is giving me.

    So, this is what I have if someone could look at it and tell me what they think....

    Patient is seen for history of skin cancer on the L arm. Diagnosed and treated in 2013. Wants it looked at.
    Patient is also seen for a lesion on their face. It is pink in color and itchy.

    PFSH reviewed and updated.

    ROS was constitutional, hemat, and integumentary

    Exam included the following:
    Derm Exam - the following areas were examined by inspection and/or palpation and found to be normal except as noted in the significant findings below: scalp / hair, head / face, neck, left axilla, right axilla, chest, abdomen, back, left upper extremity, right upper extremity, left lower extremity and right lower extremity

    Constitutional -Level of distress - Normal. Nourishment - Normal. Overall appearance - Normal.

    Eyes - Conjunctiva - Right: Normal, Left: Normal.

    Nasopharynx - Lips/teeth/gums - Normal. Tongue - Normal

    Psychiatric - Orientation - Oriented to time, place, person & situation. Appropriate mood and affect.


    One AK on the face was treated via cryosurgery.

    Treatment summary of the History of skin cancer is to come back in a year, wear sunscreen, and it is well healed with no signs of recurrence.
    What are your thoughts on the E/M code for this? The AK is out of the picture as we performed a procedure on it....all I can take into consideration is the info related to the history.

    April Sue

  2. #2
    Dover Seacoast New Hampshire
    There is no reportable E&M. Your provider has performed an AK destruction, which is a minor procedure. The E&M is bundled into the procedure, which is all you'd be able to bill. I don't see anything significant enough to report a separate office visit, and CCI has been very clear about bundling E&M into minor procedures.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. #3
    I agree with Pam's reply, but also would like to address your statement that you were told that a personal history of skin cancer would not net you any higher than a 99212. Where did you hear that? I am not aware that this is the case.

    Let's say a patient comes in with personal history of skin cancer and the findings today are all negative. There should be no problem getting an expanded history. If you do a full skin exam, that's detailed exam. So even without an MDM, as long as this is an established patient, you've got a 99213.

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