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Thread: Derm exam

  1. #1
    Join Date
    Apr 2007
    Location
    Wilmington, NC
    Posts
    32

    Default Derm exam

    Promo: Code Books
    Derm coders, my physician has a new statement he is using. Instead of naming all the body parts he has examined, he is now stating "I have done a full skin examination today and have found no other areas of frank melanoma”. I cannot figure out where he comes up with something like this. How many bullets would you give for this statement? I need some backup before I go back to him on this.

    Thanks.

    Cyndi

  2. #2
    Join Date
    Apr 2007
    Location
    Milwaukee WI
    Posts
    4,451

    Default 1997 Skin exam

    The following is PART of the exam under the 1997 specialty exam for skin

    Inspection and/or palpation of skin and subcutaneous tissue (e.g. rashes, lesions, ulcers, susceptibility to and presence of photo damage) in eight of the following ten areas:
    * Head, including the face and
    * Neck
    * Chest, including breasts and axillae
    * Abdomen
    * Genitalia, groin, buttocks
    * Back
    * Right upper extremity
    * Left upper extremity
    * Right lower extremity
    * Left lower extremity


    If you physician has stated he "did a full examination of the skin" then I'd give him credit for the above bullets.

    Of course, that is only going to help you if you are using the 1997 special exam guidelines for auditing the entire note.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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