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skin vs multi multisystem exam

Charlene Posted Sun 23rd of February, 2020 21:58:10 PM
A plastic surgeon is joining our practice and not only is this a new specialty for us, this is the physician's first position. The physician and I will review coding and documentation guidelines, and I'm unsure if the skin exam or general multisystem would most beneficial for focused issues such as skin lesion excision. A new patient with a new problem such as a minor skin excision with concern for healing complications due to diabetes being of moderate complexity would require a comprehensive exam to match the moderate MDM. The skin exam requires documentation of at least 8 skin areas plus the rest of the exam and general multisystem exam require documentation of 8 or 9 systems depending upon 1995 or 1997. I'm wondering which exam dermatology or plastic specialties find most appropriate? I know specialties are not limited to a particular exam. Any E&M guidance for plastic surgery would be helpful.
SuperCoder Answered Mon 24th of February, 2020 10:00:01 AM



For skin speciality, 97 E/M guidelines will be most beneficial. 97 E/M guidelines offers physicians an opportunity to ethically code at a higher level and get reimbursed for the services they are already providing.


In E&M coding physical exam and MDM are calculated individually and not depend on each other, so it not necessary that exam should be comprehensive to match the moderate MDM.


The 1997 guidelines include specific physical exam elements that must be addressed in the provider's documentation. Think of the '97 set as following a "bean counting" approach for each element of a system the provider addresses. The 1997 version specifies exam elements for a set of single system exams in addition to a general multisystem exam, which can be advantageous when the physician completes a thorough exam of a body system. However, if the physician addresses elements other than those specified in the guidelines, he will not necessarily receive credit for that element in the level of exam. A physician may get multiple points of credit for their documentation of a single organ system, all of which contributes to a potentially higher level of exam.



Charlene Posted Tue 25th of February, 2020 21:07:08 PM
Is it correct that MDM is the over arching criterion in code selection? If so, when MDM is moderate for a new patient and new problem w/work up, the exam and history would need to meet or exceed the same level of MDM in order to code to the MDM level? The following example is a typical plastic pt scenario. Expanded problem focused history (context, duration, quality): HPI--Patient presents on referral. He had shave biopsies of 2 areas, one in Oct and another in Nov 2019 which showed BCCA with positive margins. P,F,S hx and ROS x10 are documented. Problem focused exam: Lt ear: pink, healed area at site of prior bx. Area is approx 0.5 x 0.3 cm. Depressed area of nasal tip of 0.3 x 0.4 cm. Area well healed. No erythema or bleeding, vital signs x3 documented. Moderate MDM (elective major surgery/FTSG): Recommended exc & closure of lt ear BCCA with the understanding that removal of cartilage may be needed & if margins return positive, additional surgery will be required. Recommended exc & FTSG to nasal tip with understanding if margins are positive additional surgery will be required. The procedures were reviewed including benefits, risks, incisions, patient expectations & anticipated recovery time. So while MDM is at moderate level, with only 3 HPI elements and 2 exam elements I find the code to be 99201. Is this correct? Do you have any documentation recommendations?
SuperCoder Answered Wed 26th of February, 2020 08:42:36 AM

E&M code selection depends upon three elements i.e. history, exam and MDM. Each element plays important role while selecting a code. It is not correct to say only MDM overarching criterion in code selection. There may be a possibility that the selected code results from history or exam or MDM.


As per the CMS guidelines, for new patient, all the three elements calculated individually, and the code selection depends upon the element which has lowest level..


For example, history is EPF, exam is DET, and MDM is Low. The code selection will be on the basis of history because it has lowest level i.e. EPF.


It is correct that the exam and history would need to meet or exceed the same level of MDM in order to code to the MDM level.


As per above mentioned scenario, the level of E&M will be 99202 if you are considering 2 exam elements. Problem focused exam consist only 1 system or body area. If you change exam to 1 element than it will become 99201.


Charlene Posted Thu 27th of February, 2020 09:33:01 AM
So 99202, 2 exam areas is based on 1995 guideline. And 99201, 2 exam elements are based on 1997 guideline. It sounds like 1995 exam would benefit this provider until 12 or more exam elements are documented?
Charlene Posted Thu 27th of February, 2020 10:07:20 AM
Follow up: 99202 is based 1995 due to 2 systems (skin & constitution-V/S)? Sounds like for the problem focused issues 1995 exam would be more beneficial. And the skin exam is just too extensive. They will always have at least constitution and skin system documented. Our MAC, Palmetto, does not mix systems and areas, and they require 2 aspects per body areas or systems for detailed exam per there part B policy dept.
SuperCoder Answered Fri 28th of February, 2020 08:05:41 AM


Yes, as per general coding guidelines, E&M level 99202 is based on 1995 due to 2 systems (skin & constitution-V/S). In above mentioned scenario 1995 guidelines will be more beneficial. On the other hand, if you bound to follow MAC, Palmetto guidelines, then you have to compare it with general guidelines and bill accordingly. 



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