Hot coding topics from the field
Derm Coding Consult
By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Senior Manager, Coding and Reimbursement, July 1, 2025
Academy coding staff address important coding topics each month in DermWorld Coding Consult. Read more Derm Coding Consult articles.
Navigating the complexities of dermatology coding can be challenging. The AADA coding team regularly addresses inquiries from dermatology practices and the broader medical community, compiling frequently asked questions to provide clear, practical guidance. In this article, we share expert answers to common coding dilemmas, helping you stay informed and confident in your coding practices.
Clinical vignette #1
Coding for preventive skin examination without findings
An established patient presents for his annual skin examination pursuant to a history of basal cell carcinomas, squamous cell skin carcinomas, and melanoma.
A complete skin examination is performed. No other concerns are identified today. Sun protection, including the use of broad-spectrum SPF-15 or higher sunscreen and self-skin exams are recommended treatment options. The patient is advised to follow up in one year or if he sees any changes.
Coding rationale
As documented, there are two or more stable chronic illnesses, categorized as Moderate complexity under the number and complexity of problems addressed. There is no data reviewed or analyzed thus categorizing this element as Straightforward under the amount and/or complexity of data to be reviewed and analyzed element. Discussion and recommendation for self-skin exam and OTC broad-spectrum sunscreen with SPF-15 or higher are categorized as Low complexity under patient management.
Number and complexity of problems addressed: Moderate (2 or more chronic stable illnesses [personal history of basal cell carcinomas, squamous cell skin carcinomas, and melanoma])
Amount and/or complexity of data to be reviewed and analyzed: Straightforward (no data was reviewed/analyzed)
Risk of complications and/or morbidity or mortality of patient management: Low (recommend performing self-skin examination, use broad-spectrum sunscreen SPF-15 or higher)
Therefore, this encounter would be reported as follows:
| CPT/diagnosis code | Code descriptor |
|---|---|
Z08 |
Encounter for follow-up examination after completed treatment for malignant neoplasm |
Z85.820 |
Personal history of malignant melanoma |
Z85.828 |
Personal history of other |
99213 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded |
Clinical vignette #2
Coding for preventive skin examination with findings
A 50-year-old established male patient presents for his annual skin examination pursuant to a history of squamous cell carcinoma (SCC) on the right forehead treated five years ago. He has no concerns today apart from a few scattered brown spots on the trunk that end up being benign nevi and seborrheic keratoses.
A complete skin examination is performed, and diagnoses for the visit include benign nevi on the trunk, seborrheic keratoses, lentigines, and a history of SCC. Sun protection, including the use of broad-spectrum SPF-15 or higher sunscreen, and self-skin examinations are recommended treatment plans.
Coding rationale
As documented, there are two or more self-limited or minor problems and one stable chronic illness, which is categorized as Low complexity under the number and complexity of problems addressed.
There is no data reviewed or analyzed thus categorized as Straightforward under the amount and/or complexity of data to be reviewed and analyzed element. Discussion and recommendation for self-skin exam and OTC sunscreen with broad-spectrum SPF-15 or higher are categorized as Low complexity under patient management.
Number and complexity of problems addressed: Low (2 or more self-limited or minor problems; 1 chronic stable illness [benign nevi on the trunk, seborrheic keratoses, lentigines, and personal history of squamous cell carcinoma])
Amount and/or complexity of data to be reviewed and analyzed: Straightforward (no data was reviewed/analyzed)
Risk of complications and/or morbidity or mortality of patient management: Low (recommend performing self-skin examination, use broad-spectrum sunscreen SPF-15 or higher)
Therefore, this encounter would be reported as follows:
| CPT/diagnosis code | Code descriptor |
|---|---|
D23.5 |
Other benign neoplasm of skin of trunk |
L82.0 |
Inflamed seborrheic keratosis |
Z85.828 |
Personal history of other malignant neoplasm of skin |
99213 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded |
Note: The problems identified during the encounter are listed first, followed by the personal history of malignant neoplasm code.
Clinical vignette #3
Coding for a follow-up encounter for intertrigo
A male patient previously seen a month ago presents for evaluation and follow-up for intertrigo on the gluteal cleft. During the last appointment, he was prescribed desonide topical cream, nystatin topical cream, fluconazole tablets, OTC Hibiclens® wash, and zinc oxide barrier cream.
Today, the patient states that the rash is better with medication. During the examination of the face and buttocks (excl. genitalia), findings indicated the intertrigo has resolved.
The patient is counseled on the condition and optimal skin care to prevent reoccurrence, as well as a recommendation to continue using OTC Hibiclens wash, anti-chafing barrier creams, desonide, and nystatin topical creams. The patient is also advised to discontinue fluconazole tablets. Other discussions include the adverse effects of prolonged use of topical steroids.
The patient is advised to follow up as needed.
Coding rationale
As documented, there is one acute uncomplicated illness that is categorized as Low complexity under the number and complexity of problems addressed. There is no data reviewed or analyzed thus categorizing this element as Straightforward under the amount and/or complexity of data to be reviewed and analyzed element. Discussion and recommendation to continue OTC meds and discontinue prescription drugs is categorized as Moderate complexity under patient management.
Number and complexity of problems addressed: Low (1 acute uncomplicated illness [intertrigo])
Amount and/or complexity of data to be reviewed and analyzed: Straightforward (no data was reviewed/analyzed)
Risk of complications and/or morbidity or mortality of patient management: Moderate (Prescription Drug Management [patient advised to discontinue fluconazole tablets, discussion of adverse effects of prolonged use of topical steroids])
Therefore, this encounter would be reported as follows:
| CPT/diagnosis code | Code descriptor |
|---|---|
L30.4 |
Intertrigo |
99213 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded |
Clinical vignette #4
Coding for follow-up encounter to evaluate asymptomatic lesions
An established male patient with a history of actinic keratosis, family history of non-melanoma skin cancer (NMSC) and melanoma presents for evaluation of asymptomatic lesions located throughout the body. He also has concerns about a few dark raised lesions located bilaterally of his forearms and his right leg.
A skin examination reveals hemangiomas, benign nevi, lentigines, ephelides, solar elastosis, and seborrheic keratosis located throughout the body.
The final diagnoses include seborrheic keratoses, solar elastosis, melasma, seborrheic dermatitis, rosacea, intertrigo, family history of NMSC, and family history of melanoma.
The patient is advised to perform self-skin checks, cancer ABCDEs, use of broad-spectrum sunscreen SPF-30 or higher, and to call and schedule an appointment if the moles change in shape, color, start itching, burning, or bleeding. Otherwise, the patient can follow up in one year.
Coding rationale
As documented, there are 2 or more stable chronic illnesses that are categorized as Moderate complexity under the number and complexity of problems addressed. There is no data reviewed or analyzed thus categorized as Straightforward under the amount and/or complexity of data to be reviewed and analyzed element. Discussion with the patient on skin cancer ABCDEs, a recommendation for self-monthly skin exam, and OTC broad-spectrum sunscreen with SPF-30 or higher are categorized as Low complexity under patient management.
Number and complexity of problems addressed: Moderate (2 or more self-limited or minor problems; 2 or more chronic stable illnesses [seborrheic keratoses, solar elastosis, melasma, seborrheic dermatitis, rosacea, intertrigo, family history of NMSC, and family history of melanoma])
Amount and/or complexity of data to be reviewed and analyzed: Straightforward (no data was reviewed/analyzed)
Risk of complications and/or morbidity or mortality of patient management: Low (recommend performing self-skin examination, use broad-spectrum sunscreen SPF-30 or higher)
Therefore, this encounter would be reported as follows:
| CPT/diagnosis code | Code descriptor |
|---|---|
L82.1 |
Seborrheic keratoses |
L30.4 |
Intertrigo |
L57.8 |
Other skin changes due |
L81.1 |
Cholasma (melasma) |
L21.8 |
Other seborrheic dermatitis |
L71.8 |
Other rosacea |
Z80.8 |
Family history of malignant neoplasm of other organs or systems |
99213 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded |
Clinical vignette #5
Coding for a new patient encounter with hypertrichosis
A new female patient presents for evaluation of dark unwanted hair growing on the face. The patient states that hair growth has been present since puberty. Facial examination reveals small vellus hairs on the face and upper lip. Diagnosis of hypertrichosis is made.
A discussion on temporary hair removal options including chemical depilatory, plucking, threading, waxing, or shaving, and laser hair removal or electrolysis to remove the unwanted hair permanently. The patient is advised to follow-up as needed.
Coding rationale
As documented, there is one stable chronic illness, which is categorized as Low complexity under the number and complexity of problems addressed. There is no data reviewed or analyzed, thus categorized as Straightforward under the amount and/or complexity of data to be reviewed and analyzed element. Discussion and recommendation of available treatment options and adverse effects are categorized as Straightforward complexity under patient management.
Number and complexity of problems addressed: Low (1 chronic stable illness [hypertrichosis])
Amount and/or complexity of data to be reviewed and analyzed: Straightforward (no data was reviewed/analyzed)
Risk of complications and/or morbidity or mortality of patient management: Straightforward (minimal risk of morbidity from treatment)
Therefore, this encounter would be reported as follows:
| CPT/diagnosis code | Code descriptor |
|---|---|
L68.8 |
Hypertrichosis |
99202 |
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded |
Clinical vignette #6
Encounter for squamous cell carcinoma excision
An established male patient, previously seen in clinic, presents for excision of biopsy-proven squamous cell carcinoma (SCC) on the left distal posterior upper arm. The lesion treatment option recommendation was excision, and it was scheduled during the previous appointment.
Today, the risks and benefits of therapy are discussed, including the risk of infection, scarring, bleeding, prolonged wound healing, incomplete removal, allergy to anesthesia, nerve injury, and recurrence. A consent to perform the procedure is obtained from the patient.
The lesion is excised to the layer of adipose tissue and sent to pathology for processing and histopathologic evaluation. The defect is closed with an intermediate repair. The patient is advised to perform self-skin checks, use sunscreen broad-spectrum SPF-30 or higher, and a follow-up encounter is scheduled in two weeks for suture removal.
Coding rationale
As documented, this was a previously scheduled procedure for a biopsy-proven SCC. Discussion of and counseling on smart skin cancer prevention by performing self-skin checks and use of OTC broad-spectrum sunscreen SPF 30 or higher is included in post-procedure management.
Therefore, only the procedure can be reported for this encounter as follows:
| CPT/diagnosis code | Code descriptor |
|---|---|
C44.629 |
Squamous cell carcinoma of skin of left upper limb, including shoulder |
1160x |
Excision, malignant lesion including margins, trunk, arms or legs [specify excised diameter] |
1203x |
Repair, intermediate, wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet) |
Clinical vignette #7
Follow-up encounter for evaluation of skin lesions
An established female patient presents for evaluation of skin lesions located throughout the body. Lesions have been present for years and have never been treated. The patient has no personal or family history of skin cancer.
A complete skin exam reveals benign lesions, including actinic damage, rosacea, and irritated seborrheic keratoses.
The risks and benefits of therapy were discussed, including the risk of infection, scarring, bleeding, prolonged wound healing, incomplete removal, allergy to anesthesia, nerve injury, and recurrence.
The patient was advised to perform routine self-skin checks, use sunscreen (SPF-30 or higher) for actinic damage, and monitor the benign nevi for changes. Prescription Mirvaso® 0.33% topical gel was prescribed to apply to the face daily for rosacea.
The discussion shifted to treatment options for the enlarging, inflamed seborrheic keratosis papules with cryotherapy. Discussion included risks of the procedure, including crusting, scabbing, blistering, scarring, darker or lighter pigmentary change, recurrence, incomplete removal, and infection. The patient agreed to proceed with the procedure. A consent was obtained, and three lesions located on the mid, right, and left superior upper back were treated with cryotherapy.
Coding rationale
Diagnosing, discussing treatment options, and prescribing medication to treat the benign lesions, actinic damage, and rosacea have been documented and support a distinct and separately identifiable E/M service above and beyond the work involved in the treatment of the seborrheic keratotic lesions.
Therefore, an E/M encounter and the procedure can be reported for this encounter as follows:
| CPT/diagnosis code | Code descriptor |
|---|---|
D23.5 |
D23.5 |
L57.8 |
L57.8 |
L82.0 |
L82.0 |
L71.8 |
L71.8 |
99214-25 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded |
17110 |
Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical treatment) of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions |
Clinical vignette #8
Encounter for a tangential skin biopsy
A new female patient presents for evaluation of a skin lesion located on the right forearm. The lesion has been present for six months and has not been treated before. Today, the patient states that the lesion has been bleeding, and is inflamed and painful. The patient has no personal or family history of skin cancer.
A skin exam of the trunk and extremities reveals a neoplasm of uncertain behavior (NUB) on the proximal dorsal forearm. The patient declined a full skin exam. A tangential biopsy of the skin is recommended to ascertain a definitive diagnosis.
The risks and benefits of therapy were discussed, including the risk of infection, scarring, bleeding, prolonged wound healing, incomplete removal, allergy to anesthesia, nerve injury, and recurrence.
The patient agreed to proceed with the procedure. Consent was obtained, the biopsy was performed via shave technique, and the tissue specimen was sent to the lab for histopathological examination and final diagnosis.
Coding rationale
As documented, obtaining history, review of lesion location, and discussing treatment options is included in the procedure preservice work and therefore cannot be reported with a separately identifiable E/M.
Therefore, the service would appropriately be reported as follows:
| CPT/diagnosis code | Code descriptor |
|---|---|
D48.5 |
Neoplasm of uncertain |
11102 |
Tangential biopsy of skin (e.g., shave scoop, saucerize, curette); single lesion |
Clinical vignette #9
Encounter for lesion destruction
A new female patient presents for evaluation of a skin lesion located on the right lower extremity. The patient states the lesion has been present for a year and has been changing in color but has not been treated. She has no personal or family history of skin cancer.
A skin exam of the right lower extremity reveals a verruca vulgaris located in the anterior proximal thigh. The patient was counseled on the benign nature of the lesion as well as available treatment options, including chemical, cryosurgery, curettage, or just monitoring.
The patient decided to treat the lesion with cryosurgery. Consent was obtained, and the lesion was treated. The patient was advised to follow up as needed.
Coding rationale
As documented, the patient presented with concerns about a single problem (a lesion on the thigh). The skin exam was focused on the lesion and surrounding location. Therefore, a separately identifiable E/M is not supported for this encounter.
Therefore, the service would appropriately be reported as follows:
| CPT/diagnosis code | Code descriptor |
|---|---|
B08.08 |
Other viral warts |
17110 |
Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 |
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