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E/M New Patient

Marlene Posted Sat 27th of February, 2016 09:05:41 AM

Here are my charges - Does the HPI meet the requirements to bill the e/m? A couple of payors are now auditing for the same dx being used with the e/m so worried the HPI isn't detailed enough.

99203-25 - Dx C44.622 and L57.0
17261-59 - Dx C44.622
17000 x 1 - Dx L57.0
17003 x 9 - Dx L57.0

Chief Complaint: New lesion

HPI: This is a 93 year old male who comes in for a chief complaint of new lesion on the right superior helix. The new lesion is red and mild in severity. The new lesion has been present for 3 months.

Medications - See List
Allergies - NKA
ROS - A full review of systems was performed and negative
Medical Hx - DM, HTN, Hypothyroidims
Social Hx - Unspecified

Exam: An exam was performed including the scalp (including hair inspections), Head (including face), inspection of conjunctivae and lids, neck, chest, abdomen, back, right upper extremity, left upper extremity, right lower extremity, and left lower extremity.

Findings in the above examined areas were normal with the exception of the followng:

-AK of the left distal dorsal forearm, right distal dorsal forearm, right proximal dorsal forearm, right proximal posterior upper arm, right inferior central malar cheek, right central buccal cheek, right superior helix, left superior helix, and left central forehead.
-Squamous cell carcinoma on the right dorsal wrist


Hypertrophic erythematous papules with hyperkeratoic scale
distrubuted on the arm, face, and ear.

Plan: Counseling.
I counseled the patient regarding the following:
Skin Care: Sun protective clothing and sunblock can prevent the formation of AK. AKs can resolve with cryotherapy, photodynamic therapy, imiquimod, topical 5-FU.
Expectations: AK are precancerous proliferations that occur within sun damaged skin. If untreated, a small subset of AKs can develop into Squamous Cell Carcinoms.
Contact office is: AKs fail to resolve despite treatment, or if you delvelop a side effect from therapy, such as unbearable crusting, scabbing, redness and tenderness.

Plan: Liquid Nitrogen Multi
A total of 10 lesions were treated with Liquid nitro for 1 free-thaw cycle, located on the arm, face, adn ear. The patient's consent was obtained including and not limited to risks.

2. Squamous Cell Carcinoma
Erythematous tender nodule with hyperkeratoric scale locatedo nt he right dorsal wrist.

Plan: Counseling.
I counseled patient regarding the following:
Instructions: Squamous Cell Carcinoma can be removed via surgical excision, mohs surgery or XRT. Low risk or superficially invasive SCCs on the trunk and extremities can be removed via ED&C although recurrences are higher than with excision.
Expectations: SCC are a form of skin cancer. Sun exposure, sunburns, radiation exposure, HPN exposure, immunosuppression are all risk factors.
Contact office if: patient develops any new lesions that fail to heal, ulcerate or bleed.
Plan: Cryosurgical destruction
Procedure Note:

A 0.9 cm SCC on the right dorsal wrist was treated with cryosurgical destruction. the surgical site was antiseptically prepared. The tumor was cryosurgically destroyed with LN with 2 freex thaw cycles for 3 minutes. The wound was cleaned and a dressing was applied. Patient received detailed post op instructions.

SuperCoder Answered Mon 29th of February, 2016 10:16:54 AM

Thanks for the Query

For detailed HPI we need 4 points in History. Please let me know how you are calculating the same and for the billing of new patient code with procedure code documentation given here support two separate diagnosis code that is enough for the same hence it seems no billing issue.Please share if your payer has some specific guidelines for the billing of Evaluation and management code with the procedure code or the denial reason specified by the payer.

Marlene Posted Mon 29th of February, 2016 23:05:47 PM

The dx codes for the e/m is the same as the dx codes on the procedures CPT codes. I am guided that you need to show that your providing above the normal documentation for the procedures. Each procedure has part of an e/m in the billed amount. Can you say that the HPI has enough documentation to support the e/m? I have Location (helix), Severity(mild), Duration (3 mths), associated signs and symptoms (Red).

SuperCoder Answered Tue 01st of March, 2016 09:06:15 AM

Thanks for the Query

E&M services on the same date of service as the minor surgicalprocedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M
service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses.

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