Hot coding topics to keep you cool this summer

By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, manager, coding & reimbursement, June 1, 2021

Academy coding staff address important coding topics each month in Derm Coding Consult. Read more Derm Coding Consult articles.

Think back to the world a year ago: empty streets with children and adults learning and working remotely, barren restaurants with patrons preferring to dine at home, and vacant dermatology practices due to canceled patient appointments because of the COVID-19 public health emergency (PHE). Now, fast forward a year later as we inch closer to the start of summer with more states relaxing regulations — if not already relaxed. As we embrace mask-wearing to be a norm (at least for some time) and vaccines become more readily available, soon we will begin to see the usual routines, vacations, picnics, hiking, etc. re-enter our lives.

Along with these socially distant gatherings, patients will start scheduling new and/or follow-up appointments or seek care for other summer-related ailments. As always, dermatologists will continue to provide excellent medical care that patients have come to rely upon. However, looking for those infrequent summer-related diagnoses codes can be time-consuming. As such, the AADA coding team offers the following coding tips to keep you and your staff coding-cool this summer.

Keep calm and code on

Nature hikes

“Becoming one with nature” sounds great, but coming home with a rash and constant itching is not so great. When a patient presents with constant itching due to inadvertent contact to poison oak or ivy, pollen, or any kind of plant that may have grazed the arm or leg, the diagnosis code will originate from L23.7 Allergic contact dermatitis due to plants, except food.

For purposes of evaluation and management (E/M) coding, allergic contact dermatitis could be categorized as an acute, uncomplicated illness that meets the low element criteria under the number and complexity of problems addressed.

Fun in the sun

Even sitting still can result in an injury. When a patient does not use the proper sun protection, they may end up with a sunburn. The sunburn may be reported with a variant of degrees. To report, see L55.x Sunburn (specify the degree of burn).

For purposes of E/M coding, sunburn can be categorized as an acute, uncomplicated illness that meets the low criteria under the number and complexity of problems addressed. Severe, blistering sunburn greater than 20% body surface area can be classified as an acute complicated injury that meets the moderate criteria under the number and complexity of problems addressed.

Pesky bug bites

Patients who are bitten by fire ants while camping or at the summer picnic will experience pain and itching. Those allergic to ant venom certainly have to be very careful; however, patients who present to the dermatology practice with a serious or mild case of ant bites must have a diagnosis code reported to the highest specificity. To report the encounter, remember to include the 7th character indicating the encounter status (e.g., A - initial, D - subsequent, or S – sequela).

To code the encounter, see T63.42xx Toxic effect of venom of ants after determining whether the bite(s) are intentional, unintentional, assault, or undetermined as to how the bite happened.

For purposes of E/M coding, venomous ant bites, especially if the patient is allergic to ant venom, can be categorized as an acute complicated injury that meets the moderate criteria under the number and complexity of problems addressed.

Heat rash

As temperatures rise in the summer, a common skin condition among children and adults is prickly heat rash. These tiny red bumps are itchy on the area of the skin that has been exposed to heat and sweat for a long time. To code prickly heat rash, see L74.0 Miliaria rubra or L74.1 Miliaria crystallina for the milder form.

For purposes of E/M coding, Miliaria rubra is categorized as an acute, uncomplicated illness that meets low criteria under the number and complexity of problems addressed.

More than a freckle

Patients who present with rough, pink spots due to long-term skin tanning may have a cause for concern. After obtaining a pertinent history and examination, you diagnose an actinic keratosis that is reported with L57.0 Actinic keratosis (includes senile and solar keratoses).

Actinic keratosis is categorized as an acute, uncomplicated illness that meets the low criteria under the number and complexity of problems addressed.

On the other hand, those lesions considered to be benign (e.g., seborrheic keratoses, depending on whether symptomatic or asymptomatic), are reported with L82.x. and categorized as a self-limited or minor problem which meets the criteria for straightforward under number and complexity of problems addressed for purposes of E/M coding.

Hyperpigmentation

Sun exposure can also worsen the appearance of darker patches of the skin. As patients spend more time in the sun, they will schedule appointments for the dermatologist to address the tan-brown patches on the face. After obtaining a pertinent history and examination, you diagnose the female patient with melasma. Counseling on the nature of their chronic condition and skin protection with daily use of broad-spectrum sunscreen before they venture into the sun is provided. The diagnosis reported is L81.1 Chloasma which is categorized as low criteria under number and complexity of problems addressed.

Frequently Asked Questions (FAQs) for practical applications of the 2021 E/M coding changes

Question: With the state stay-at-home orders relaxed, an established patient presents for their annual exam. You perform a medically appropriate skin examination and identify a couple of actinic keratoses that are treated with cryosurgery. You also identify an angioma and some lentigos and reassure the patient as to their benign nature.

The patient also has a history of eczema that was previously treated with a prescription topical steroid. Today, however, there is no eczema present. After discussion of the risks, benefits, and/or alternative treatment options with the patient, you renew the prescription for the same topical steroid for the patient to use as needed and advise them to use moisturizers and sunscreens.

What is the appropriate E/M code for such an encounter?

Answer: Based on the documentation above, the actinic keratoses are treated with cryosurgery (minor procedure). Minor procedures include pre-, intra-, and post-procedure work inherent in the procedure. To report an E/M code, a significant, separately identifiable service must be performed on the same day. As such, documentation pertaining to the surgery is not counted toward the choice of the E/M code.

This leaves all other problems addressed to be considered in the E/M code selection. To report an E/M code, one must meet or exceed 2 of the 3 medical decision-making elements:

Complexity and number of problems addressed: Low (Angiomas, lentigos, eczema – 2 or more self-limited, minor problems; 1 stable chronic illness) [AMA: Do not sum up the problems addressed to report a higher level in the element]

Amount and complexity of data to be reviewed: Straightforward – (None)

Risk of complications and morbidity: Moderate – (Prescription drug management)

E/M code: 99213

Question: A new patient presents with a lesion suspicious of basal cell carcinoma (BCC) on the nose. The patient refuses any further examination. You perform a tangential biopsy of the suspicious lesion. The patient is advised that staff will contact them when the biopsy results are ready so you can discuss further treatment options depending on the final diagnosis.

What is the appropriate E/M code for this encounter?

Answer: Minor procedures include pre-, intra-, and post-procedure work inherent in the procedure. To report an E/M code, a significant, separately identifiable service must be performed on the same day. The documentation indicates that there was no other service provided other than the tangential skin biopsy (minor procedure).

As such, the documentation presented does not meet the criterion of modifier 25, and only the minor procedure code is reported.

CPT code: 11102

Question: The same new patient in Q2 presents with a lesion suspicious of BCC, but instead of performing the biopsy during the encounter, you discuss the purpose and risks of the procedure and schedule it for a different date of service due to scheduling issues. You also counsel the patient on the importance of using a broad-spectrum sunscreen with sun-protection factor (SPF) 15 or higher.

What is the appropriate E/M code for this encounter?

Answer: Because the procedure is scheduled for a different day, the time spent discussing the upcoming procedure (that may include the risks, outcomes, etc.), is counted toward the appropriate choice of the E/M service.

The suspicious lesion is considered an undiagnosed new problem with uncertain prognosis and is categorized as moderate under the number and complexity of the problems addressed.

The documentation further indicates discussion to perform a skin biopsy (minor procedure) which is scheduled for a different day. This meets the criterion for moderate under risk of complications and patient management. There is no data reviewed. As such, this encounter would be reported as:

Complexity and number of problems addressed: Moderate – (Undiagnosed new problem with uncertain prognosis)

Amount and complexity of data to be reviewed: Straightforward – (None)

Risk of complications and morbidity: Moderate – (Decision to perform minor surgery)

E/M code: 99204

Question: An established patient presents for a follow-up encounter for acne that has markedly improved but not completely cleared. The patient states they have no side effects from current medications. You advise the patient to continue taking the present prescription for which they have enough refills left on the order. The discussion is then documented in the patient medical record. What is the appropriate E/M code for this encounter?

Even though the patient is responding well to the treatment and appears to be stable, they are still not at their treatment goal. The American Medical Association (AMA) guidelines state that patients with a chronic condition who are not at treatment goal "are not considered stable." Further, the guidelines state that prescription management must include a discussion and documentation of the risks, benefits, and/or alternative treatment options to be considered "management," regardless of whether a prescription is written or not. As such, this encounter will be reported as follows:

Complexity and number of problems addressed: Moderate – 1 or more chronic illnesses with poor progression (Acne not at treatment goal)

Amount and complexity of data to be reviewed: Straightforward – (None)

Risk of complications and morbidity: Moderate – (Prescription drug management)

E/M code: 99214

Explore more information and resources to help you address the 2021 E/M coding challenges.

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