Vaida Posted Wed 01st of May, 2013 15:21:04 PM
I am aware that Dermatologists do not bill preventive codes, but how to document a visit, when a new patient has no concerns, has no family or personal history of skin cancer or atypical moles and he came in for "skin exam" only? There is nothing we can document in HPI except that he denies suspicious skin lesions. So if a full body exam was done for this patient with only a few benign findings (angiomas) documented in the exam and the diagnosis in 216.8, can we bill 99201 even though there in no HPI?
SuperCoder Answered Fri 03rd of May, 2013 10:54:51 AM
Many insurance companies may not recognize preventive skin cancer screenings as being preventive medicine services otherwise reported using codes (99381-99397), since those codes describe "comprehensive" services that include an age and gender appropriate history and examination and other elements that may not be part of skin cancer screening. If that is the case with the payer in question, look instead at using an appropriate office or other outpatient visit code from the 99201-99215 range, such as CPT® 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...) or 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ...), with V76.43 (Special screening for malignant neoplasms; skin) as the diagnosis.
Important: Always select the E/M level based on actual documentation in the medical record. These visits can vary greatly depending on the patient's sun exposure, family history, number of existing nevi/lesions, and other factors.
Much better: If the patient has a history of skin cancer, look for other V codes that may further support the medical necessity of the service, like V13.3 (Personal history of other diseases; diseases of skin and subcutaneous tissue). Including a V code such as this might increase your chances of reimbursement, but always check payer guidelines before submitting your claim.
Vaida Posted Fri 03rd of May, 2013 13:05:04 PM
Thank you for your response, but this does not answer my question, which was: if a patient comes in with a chief complaint of "skin exam", has no history of personal or family skin cancer, no suspicious skin lesions and a full body exam is done on this patient with positive findings of benign skin neoplasms only, reassurance is given to the patient that these lesions are benign and no further treatment is necessary, can we bill 99201 even though there are no HPI factors recorded in HPI? Please clarify. Thank you in advance!
SuperCoder Answered Tue 07th of May, 2013 20:57:12 PM
Thanks for the concern. My Senior editor is working on this and we will respond you soon.
SuperCoder Answered Thu 23rd of May, 2013 17:25:02 PM
There should be some HPI, it may just all be negative.
People usually don't come in with no concerns for a skin check.
"I'm here for a skin check" "Any concerns?" "No just a couple of spots I've had for years"
Here is the HPI: moles on right back, hip and left thigh (location), no change in size or color (quality), all have been there for years (duration), no itching, burning or pain (associated signs and symptoms)
So it may be more of poor or missing documentation, rather than no HPI
Often the area that indicates HPI may be blank but the information can be found in the note.
To be black and white, no HPI, no new visit.