Applying the 2021 E/M coding concepts in everyday practice – Part 6

Part six of the Academy’s clinical vignettes focuses on the application of coding concepts related to E/M encounters. These clinical vignettes demonstrate how a single condition can be categorized under different categories of problem addressed during the encounter depending on disease severity and patient presenting circumstances at the time of the encounter. Missed the previous articles? Review them at Derm Coding Consult.

Clinical vignette 20

50-year-old patient with history of extensive sun exposure and sun burns and a family history of melanoma in both her sister and mother presents with a slowly enlarging irregularly pigmented patch on her cheek. Dermoscopic evaluation reveals an atypical pigment network with reticular pattern and evidence of regression. There is a blue-whitish veil and gray-blue areas with irregular extensions.

The lesion is highly suspicious for melanoma in situ or early invasive melanoma.

The differential diagnosis is discussed with the patient as well as the diagnostic options. The risks and benefits of an incisional biopsy are discussed including the risk of significant post-operative bleeding due to her Coumadin medication. The PCP’s note is reviewed, which includes blood work (INR and CBC ordered by the patient’s PCP) that reveals an INR of 2.5 and a CBC within normal limits. The procedure is scheduled.

Rationale

The problem addressed in this example is an undiagnosed new problem. Based on the patient’s personal and family history as well as the dermatologist’s assessment, the prognosis of the lesion is uncertain supporting a problem addressed at the moderate level for the MDM element.

• The AMA defines an undiagnosed new problem with uncertain prognosis as a problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.

The amount and complexity of data reviewed and analyzed for this encounter includes the review of the results of two unique tests previously ordered by the primary care provider to assess the risk to the patient of the procedure under consideration.

However, as the results were received from an external (unique) source, the patient’s primary care provider, they are categorized as review of prior external notes from a unique source.

• The AMA has clarified that external records include communications and/or test results from an external physician, other qualified health care professional, facility, or health care organization.

  • An external physician or other qualified health care professional who is not in the same group practice or is of a different specialty or subspecialty.

• A unique source is defined as a physician or qualified heath care professional in a distinct group or different specialty or subspecialty, or a unique entity.

• Review of all materials from any unique source counts as one element toward MDM.

The level of risk of patient management options in this encounter involves the decision for surgery for a procedure scheduled at a later date.

• The AMA indicates that a minor surgery with identified patient or procedure risk factors is at the moderate level of risk. Alternatively, a minor surgery without identified risk factors would be considered one at the low level of risk.

• Identified patient or procedural risk factors are those risks identified in the medical record that are above and beyond those typically associated with the procedure.

As the medical record in this example indicates an increased patient/procedural risk as the patient is on coumadin, the level of risk of patient management is moderate for this MDM element.

Clinical vignette 21

A healthy 42-year-old patient presents for consideration of treatment of a biopsy-proven melanoma in situ of the left bicep, present for 6 months. The lesion is a well-defined tan-brown reticulate patch measuring 1.2 cm.

The biopsy report from the primary dermatologist is reviewed and reveals in situ melanoma, extending to tissue edges. The patient’s records from her PCP are reviewed, along with a photo. The patient is on no anticoagulants and has no risk factors.

Surgery with direct closure with a 5 mm margin is recommended and scheduled under local anesthesia.

Rationale

In this example, the problem addressed is a small biopsy-proven melanoma in-situ on the extremity. While the possibility of finding histologic invasion after excision of such lesions exists, typically, the MMIS in this straightforward clinical scenario will be treated without complicating factors. In this case the problem addressed is categorized as an acute, uncomplicated illness or injury (low complexity) based upon the disease severity and presenting circumstances at the time of the encounter.

• The AMA defines an acute, uncomplicated illness as one for which there is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.

The data reviewed and analyzed in this encounter includes prior external notes from two unique sources meeting the criteria of two elements of data needed for the low level for the MDM element.

• The AMA defines a unique source as a physician or qualified health care professional (QHP) in a distinct group or different specialty or subspecialty, or a unique entity.

• The AMA further clarifies that review of all materials (e.g., notes, test reviewed, etc.) from any unique source counts as one element toward this MDM element.

The level of risk of patient management options in this encounter also involves the decision for surgery for a procedure that will take place on a different day. However, there are no identified patient/procedure risk factors noted in the medical record. As such the level of risk of patient management is categorized as low for this MDM element.

Clinical vignette 22

A 69-year-old patient presents for consideration of treatment of a biopsy-proven melanoma in situ of the lentigo maligna type. The lesion is a 3.2 cm ill-defined brown, tan, and reticulate black patch of the left zygoma, extending toward the lateral canthus.

The biopsy report is reviewed and reveals extensive in situ melanoma with follicular involvement and possible regression, extending to tissue edges. The patient’s dermatology records are reviewed along with a photo of the biopsy and prior INR result from the PCP. The glass slide is requested, reviewed, and findings are documented in the medical record. The patient is on Coumadin with a constant, longstanding dose and has an INR of 1.9 to 2.3 for chronic AFIB.

The patient is scheduled for Mohs surgery with MART-1 immunostains to be performed under local anesthesia with the likelihood of a flap or graft closure or significant reconstruction if needed to retain eyelid function. There is the potential that invasive disease will be identified and that a sentinel lymph node biopsy will be needed.

Rationale

The problem addressed in this example is melanoma in situ, a new problem for the dermatologist. Additionally, the medical record states that there is a potential for invasive disease yet to be identified, elevating the condition in complexity to a new problem with an uncertain prognosis.

• The AMA states that the assessment of the level of risk (from the condition) is affected by the nature of the event under consideration.

• Further, while the risk of morbidity/mortality of the condition and management risk may correlate, the risk from the condition is distinct from the risk of patient management options.

Therefore, the problem addressed in this example is categorized at the moderate level for this MDM element.

The amount and complexity of the data reviewed for this example includes review of the patient’s records from an external source and independent interpretation of a test not ordered or reported by the dermatologist providing the evaluation and management encounter.

• Per the AMA, if a test/study is independently interpreted in order to manage the patient as part of the E/M service, but is not separately reported, it is taken into consideration when determining the complexity of the MDM.

• Documentation of the interpretation of the test result must be documented in the medical record, however the interpretation need not conform to the standards of a complete report for the test.

In this example the risk of patient management is complicated by the possibility of invasive disease and a major procedure (flap or graft) with excisional / Mohs surgery at the lateral canthus likely requiring a significant reconstruction with procedural risk factors potentially affecting eyelid function and patient risk factor of excessive bleeding on anticoagulation.

• The level of risk of patient management is based upon the probability and/or consequences of the problem(s) addressed at the encounter when appropriately treated.

• The AMA further defines the risk of patient management options based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty.

Due to the increased level of complexity in the management of this patient as well as the documented patient/procedural risk factors associated with the patient’s Coumadin therapy and potential for loss of eyelid function, this MDM element is categorized as high.