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Dermatology encounter

Cheryl Posted Tue 07th of May, 2019 18:11:24 PM
I was wondering if you would code the following dermatology (established patient) visit as I would like a second opinion on either to code a procedure only or procedure and E/M: Patient returns for routine f/u. Since last seen patient reports doing well. Has several crusty areas of scalp and cheek. Asymptomatic. Unchanged. No bleeding but notes crusting on left cheek. New area on right cheek. PE: Pink macules consistent with well healed scars. Erythematous scaling macules including left cheek, scalp X2, left forearm X3. Waxy plaque left cheek. The remainder of exam including face,scalp,ears,neck,chest, back, upper extremities,hand,lower extremities,feet, buttocks w/o suspicious lesions. PMH: NMSC, AK's, SK's. PLAN: AK's-consent obtained and above areas treated with liquid nitrogen 5-8 seconds X2. No immediate complications, LN2 left cheek, scalp X2, left forearm X3. NERD:Signs of skin cancer reviewed with patient. SK's: Patient reassured this is benign thickening of skin. No treatment.
SuperCoder Answered Wed 08th of May, 2019 10:17:27 AM


Thanks for your question.

When a procedure is schedule for a visit then only procedure will be coded for that visit. Since, in this scenario patient came for a followup visit and as per the documentation he/she was not schedule for any procedure on this DOS therefore E/M code 99213 (based on limited documentation) will be billed.

As per the limited documentation, we are able to find that the provider treated with liquid nitrogen. The codes that can be billed are as follows:



ICD-10: L57.0 and L82.1

Hope this helps.


Cheryl Posted Wed 08th of May, 2019 18:53:24 PM
I thought that an E/M is included in a minor procedure unless the documentation went above (significant and separate) from what is normally routine for this type of procedure and it did not seem to me that there was in this case.
SuperCoder Answered Thu 09th of May, 2019 10:09:08 AM


The reason for visit will be the first thing to check. In this scenario the patient came in for a follow up visit. If the provider did a procedure in initial visit that has a global period of 10 days (minor procedure) then in the next visit (within 10 days global period) there will be no E/M billed for that follow-up unless there is any new problem to the patient. 

Since, in your case the intent of the visit was follow-up and not any procedure, follow up evaluation by the provider lead to the diagnosis of new problem/problem at new areas (Right cheek). Provider decided to perform the procedure for the new problem identified during the visit which makes it separate identifiable service. Since the service is separately identifiable, E&M code would be billed along with the procedure code.

Hope this helps.


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