Applying the 2021 E/M coding concepts in everyday practice – Part 7

Part seven of the AADA’s clinical vignettes focuses on the application of coding concepts related to E/M encounters. These clinical vignettes demonstrate how, a common dermatologic condition, actinic keratosis in these examples, 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 23

Patient with many years history of diffuse AKs on the face elected, after a discussion with his dermatologist, to undertake field therapy and was treated at the last visit with topical imiquimod 5%. He has had an appropriate exuberant inflammatory reaction and the medicine is discontinued on a previous visit. The patient presents today for a follow up after finishing treatment and evaluation of AK resolution.

Exam reveals minimal areas of scaling, erythematous macules, with no clearly definable AKs present.

Both the patient and dermatologist are satisfied with the results and agree that no further treatment will be done at this time and treatment goal was achieved. The patient, because of his history with actinic damage, will be monitored periodically for development of new lesions.

Rationale

In this example, the problem addressed is a single stable chronic illness that requires no additional treatment.

• The AMA defines a chronic condition as a problem with an expected duration of a least a year or until the death of the patient.

• Further, the AMA defines stable for the purposes of categorizing medical decision making as a condition at specific treatment goals for that individual patient.

As documented, the condition has been present for many years supporting the AMA’s definition of a chronic condition and no further treatment is considered during the encounter, indicating that the patient is at treatment goal. The AMA states in part that “stable” for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.

As such the problem addressed in this encounter is at the low level for this MDM element.

The AMA guidance above does not specifically define who determines if the treatment goal has been attained. As such, achieving treatment goal may be determined by either the patient or the dermatologist. However, there may be circumstances when the two parties do not agree. In these instances, documentation in the medical record should reflect the dermatologist’s clinical judgement of the condition’s stability and the risk of morbidity without treatment. Similarly, the dermatologist must document when a patient does not feel that they are at treatment goal contrary to the dermatologist’s clinical judgement and treatment is discontinued or altered.

For example, a patient with a malignancy refusing treatment claiming that they simply prefer to “monitor” would not be considered at treatment goal despite refusing treatment.

No data was reviewed or analyzed during this encounter. Minimal or no data analyzed during the encounter is considered a straightforward level for this MDM element.

The final MDM element is the risk associated with management of this patient. In this example the management of the patient involves periodic monitoring for progression or recurrence.

• The AMA defines risk as the probability and/or consequences of an event and the assessment of the level of risk is affected by the nature of the event under consideration.

As the condition in this example is a stable chronic condition and patient management is documented as monitoring, the risk for this MDM element is straightforward.

Clinical vignette 24

A 70-year-old male presents for thin-rough spots on the forehead present for the past year. He notes they have not changed and are not bothering him.

You diagnose actinic keratoses, educate on diagnosis and risk of malignant transformation, and recommend strict photoprotection with broad spectrum sunscreen SPF 30+.

You offer treatment options including cryotherapy and topical 5-fluorouracil. Patient declines treatment as the spots are not bothering him and agrees to clinically monitor for any change.

Rationale

This encounter also describes a chronic condition that meets the AMA’s criteria of a stable chronic condition.

• As the patient is declining treatment in this example, he is considered to be at his treatment goal.

No data was reviewed or analyzed during this encounter.

• Minimal or no data analyzed during the encounter is considered a straightforward level for this MDM element.

Though the patient elected not to treat the lesions at this time, the highest level of risk of patient management options for this encounter involves discussion of a potential prescription drug to treat the lesions.

• The AMA further clarifies that risk includes the possible management options selected as well as those considered, but not selected, after sharing the plan of care with patient and/or family.

Consequently, the level for this MDM element is moderate.

Clinical vignette 25

A 40-year-old male presents as a new patient with scattered rough areas on his scalp that have been present for several months.

You identify about a dozen actinic keratoses confined to the scalp and discuss cryotherapy versus topical therapy. The patient opts for topical therapy.

You discuss the risks and benefits of topical 5-fluorouracil cream, provide instructions and expectations for use, and schedule follow up in 3-4 months to assess response to therapy.

Rationale

Based on the documentation, this encounter describes an acute uncomplicated illness with a duration of less than one year.

• The American Medical Association (AMA) defines an acute uncomplicated illness or injury as a recent or new short-term (less than one year duration) problem with low risk of morbidity for which treatment is considered.

• Acute uncomplicated illnesses pose little to no risk of mortality with treatment, and full recovery without functional impairment is expected.

No data was reviewed or analyzed for this encounter, so this MDM element would be considered straightforward.

The highest-level risk of management options discussed/selected in this encounter also involves prescription drug management and fulfilling the moderate level of risk.

• Documentation of the encounter includes discussion with the patient of potential side effects of the prescribed treatment, meeting the AMA’s requirement for selecting prescription drug management, fulfilling the criteria needed for a moderate level of risk.

Coming soon, part eight in this series will continue to demonstrate how actinic keratosis can be categorized under different categories of problem addressed during the encounter. Specifically, part eight in this series will address level four examples and encounters with minor procedures performed on the same day as the evaluation and management of AKs.