Evaluation and management: Selecting the codes
Cracking the Code
Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.
By Alexander Miller, MD, September 3, 2018
You have evaluated a patient, and now it is time to select an appropriate level of new or established evaluation and management (E/M) code. Your electronic health records (EHR) program may provide a code level based upon data entered in the patient record. Is the selected code reasonable? That depends upon whether the information in the patient record supports the code level, and whether the gathered information is relevant for the problem(s) evaluated.
You may be tempted to produce considerable history and examination material, or your EHR may prompt you to obtain more information. Alternately, history facts such as past medical history gathered during previous visits may automatically populate a subsequent visit data set. A physical examination may be extensive, but was all of that relevant to and necessary for the evaluation of the presenting problem(s)? If yes, then great, go ahead and count it toward determining a level of E/M. However, if accumulated charted data is irrelevant or unnecessary for an evaluation, then it is not to be used for determining a level of E/M service.
Let’s say that you saw an established papular and comedonal acne patient, previously documented as otherwise in good health with no ongoing other medical problems. You are treating the patient with topical medications.
- Is it necessary to extensively re-document a past medical and family history, except for any interim changes?
- Does the patient need a complete skin examination, palpation of lymph node basins and of the thyroid?
- Do eyes, conjunctivae, and oral mucosae need to be examined?
I have seen such information repeatedly listed in a patient’s EHR for every acne patient visit. Sure, the data will seem to validate upcoding to a higher level of E/M service, but was any of this service really needed? One would even wonder, was it really done, or was it the product of check-off lists in the EHR?
An auditor reviewing such a chart would be suspicious of both cloning of data from prior visits and of upcoding via aggregation of data immaterial to the presenting problem(s). Watch out, as a pattern of such coding may result in a focused audit of multiple charts, a reduction in E/M level from that originally billed, and a demand for a refund. If such a demand were extrapolated to an entire insurer’s array of similar charges over time, it could amount to an uncomfortably large sum. Moreover, if Medicare were to find a pattern of “abuse,” one could be subjected to prepayment audits of all E/M charges. That would be a pain!
Appendix C of the CPT® “Coding Examples” includes a variety of dermatology-specific clinical vignettes that may correspond to various levels of E/M services. Let’s select a few, and extract elements that would validate a given code level from a coder’s and auditor’s perspective.
Patient vignette 1
“Initial office visit for a 65-year-old male for reassurance about an isolated seborrheic keratosis on upper back.”
Chief complaint: Dark bump on back
History: Back spot (location) recently noted (time) by patient’s wife, who is concerned about the darkness of the spot.
Examination: 1-cm-wide “stuck on” brown, dry, flat, sharply defined papule on the left upper back
Diagnosis: Seborrheic keratosis
Plan: Patient counseled, no treatment needed
Key components of evaluation:
History: Chief complaint, brief history of present illness (2 elements of history); no review of systems or past history necessary
- Conclusion: Problem focused history
Examination: Only one anatomical area (back) examined - Conclusion: Problem focused examination
Medical decision making: One diagnosis option, minimal data review, minimal to no risk of morbidity - Conclusion: Straightforward medical decision making (MDM)
Patient vignette 2
“Initial office visit for a patient with a clinically benign lesion or nodule of the lower leg that has been present for many years.”
Chief complaint: Bump on right leg for years
History: Unchanging (quality or severity), asymptomatic (quality or associated signs and symptoms) bump on the right lower leg (location) for several years (duration). No treatment. No other similar bumps elsewhere on skin (one system reviewed).
Examination: Skin examined on all four extremities, chest, back
Diagnosis: Dermatofibroma
Plan: Patient counseled, no treatment recommended
Key components of evaluation
History: 4 history of present illness (HPI) elements, one system reviewed (skin)
- Conclusion: 4 elements of HPI (extended history), one system reviewed: Extended history but only one review of systems. Expanded problem focused history
Examination: 6 examination bullets
- Conclusion: Expanded problem focused examination
Medical decision making: Minimal differential diagnosis options, no data review, minimal risks
- Conclusion: Straightforward MDM
Patient vignette 3
“Initial office visit for a diffusely photodamaged patient with multiple crusted lesions.”
Chief complaint: Scaly bumps on scalp, face, and arms
History: Rough, scaly, locally tender (quality) lesions on scalp, face, and arms skin (location) that have persisted since appearing and have gradually worsened and multiplied (severity) over several years (duration), with some lesions bleeding and crusting (associated signs). Use of moisturizer has not improved the lesions (modifying factors). Right scalp and left forearm (location) moderately (severity) tender to pressure (quality) growths have been present for one month (duration) and have been enlarging (associated sign).
Review of systems: Constitutional (no weight loss, fatigue), integumentary (no other areas of new growths, tenderness), hematologic/lymphatic (no growths or tenderness in neck, parotid areas, axillae)
Past, family, social history: No personal history of skin cancers; family history of basal and squamous cell carcinomas; history of 5 years lifeguarding on beach, and golfing.
Examination: Complete skin examination (list each individual bullet point of examined skin) including scalp, and lymph node palpation of neck and axillae
Diagnosis:
- Actinic keratoses (AKs)
- Suspected squamous cell carcinomas (SCCs): Right scalp and left forearm
- Photodamage
Plan:
- Discussed need for treatment of AKs; plan to treat topically
- Discussed, scheduled for surgical removal of the SCCs
- Discussed photodamage mitigation strategies
Key components of evaluation
History: 6 HPI elements, 3 systems reviewed, 3 elements of personal, family, social history
- Conclusion: Detailed history
Examination: 2 organ systems, 12 total bullets (11 for complete skin examination, 1 for 2 lymph node areas)
- Conclusion: Detailed examination
Medical decision making: Limited diagnoses and management options; low to moderate risk of morbidity.
- Conclusion: Low to moderate complexity MDM
Patient vignette 4
“Initial office visit for a patient with a personal history of multiple nonmelanoma skin cancers who presents with a rapidly enlarging 2-cm nodule located on the left temple along with associated tingling in the area and fullness of the subcutaneous tissue in the left preauricular region.”
Chief complaint: Enlarging, tender growth on the left temple
HPI: 2 month duration (duration) of an enlarging, throbbing, and locally tingling (quality), moderately tender to pressure (severity) growth located on the left temple (location) at the site of a squamous cell carcinoma treated with curettage and electrodesiccation 6 months ago (context)
Review of systems: Pertinent review of constitutional, eyes (vision changes), ears/nose/throat symptoms, respiratory (shortness of breath, dyspnea), musculoskeletal (joint pains), integumentary (lesions elsewhere), neurological (other paresthesias, analgesias, headaches), psychiatric (depression related to growth), lymphatic (growths, tenderness in lymph node basins), allergic (reactions to prior therapies). This constitutes a complete review of systems.
Past, family, social history (PFSH): Fully reviewed for personal history of malignancies, other tumors; medication list; drug allergies; family history of malignancies; other drug use, prior UV exposure, exposure to carcinogens.
Examination: Two or more bullets from constitutional (appearance, or 3 vital signs); eyes; ears, nose, lips, oral mucosa, tongue; complete skin examination (list each individual bullet point of examined skin); palpation of all lymph node basins, percussion over named nerves coursing in vicinity of mass, sensory examination of left face and scalp; neck palpated for masses, tenderness, thyroid enlargement; digits and nails examined; psychiatric (mood, affect); orientation
Diagnosis: Probable recurrent aggressive squamous cell carcinoma with perineural invasion and preauricular lymph node metastasis.
Plan:
- Imaging studies scheduled
- Consultation with head and neck surgery, radiation oncology
- Discussion with patient
Key components of evaluation
History: 5 HPI elements, 10 systems reviewed (complete review of systems), complete PFSH
- Conclusion:Comprehensive history
Examination: 2 or more bullets from 9 organ systems - Conclusion: Comprehensive examination
Medical decision making: Undiagnosed new problem (tumor) with uncertain prognosis; multiple management options, moderate to high risk of morbidity and mortality - Conclusion: Moderate complexity MDM
