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Work Pe With Lesion Removal

  1. #1
    Default Work Pe With Lesion Removal
    Medical Coding Books
    A Patient Came In Today For A Scheduled Lesion Removal. I Will Code It When The Pathology Results Come Back Indicating If It Is Benign Or Malignant. She Also Brought A Form From Her Employer, An Employee Medical Form. It Consisted Of Name, Address, Sex, Blood Pressure, Mantoux Test (which Someone Wrote In On That Line, "not Needed, Received 7/3/07 With 0 Results), And Chest Xray (which Someone Wrote (n/a Unless Md Indicated). There Was A Statement On The Form Preprinted Which Read "i Have Examined The Above Employee And Found No Evidence Of Disease In A Communicable Form. There Is No Evidence Fo Boils Or Infected Wounds. There Is No Evidence Of Any Health Impairments Which Might Pose A Risk To The Residents Of The Adult Home Or Interfere With The Performance Of This Individual's Duties" And A Place For The Doctor To Sign.

    The Employer Will Pay Up To 80.00 For An Employee Physical Including Mantoux, Further Charges For The Date Of Service Are Payable By The Employee. The Patient Is Self Pay With No Insurance.

    Would I Code This As A Lesion Removal Only And Bill The Patient?

    Besides The Form The Employer Provided, I Have A Soap Note With Name, Dob, Allergies, Latex Allergies, Tobacco Use, Immunizations, T, P, Rr, Bp, H, W, C.complaint, No Ros Or Hpi, Examination Of Skin With Size Of Lesion And Description Of Procedure And Excision, Heart - Normal, Assessment: Skin Lesion Back.

    Would I Bill This As A Lesion Removal Only And Bill The Patient? I Do Not Feel That The Examination Justifies A 99455.
    Heather Winters, CPC, CFPC

  2. #2
    Duluth, Minnesota
    I would bill the lesion removal to the patient (self pay) as you say. I would bill a low level E/M (what documentation supports) with the V70.5 for the "work" part of the visit (filling out forms, brief exam of patient, review of forms) to the Employer. Obviously, this is the form they require for "employee health check".
    Donna, CPC, CPC-H

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