Applying the 2021 E/M coding concepts in everyday practice – Part 8

Part eight of the AADA’s clinical vignettes focuses on the application of coding concepts related to E/M encounters. These clinical vignettes continue those of part 7 in this series, demonstrating how a common dermatologic condition, actinic keratosis, can be classified 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 26

A 68-year-old female patient with a history of actinic keratoses (AK) for many years treated unsuccessfully with cryotherapy and a history of numerous non-melanoma skin cancers (NMSC) presents with complaints of persistent scaly bumps on her face. She has a history of recurrent herpes simplex virus (HSV) breakouts on her forehead, but none recently.

Your evaluation reveals numerous actinic keratosis over the face with some areas of near confluent involvement.

Treatment options are discussed. You and the patient decide that photodynamic therapy is the best option, balancing field therapy with faster recovery.

You discuss the procedure and the benefits and risks including the possibility of HSV reactivation with treatment. The patient already has a prescription for famciclovir and is instructed on taking it prior to PDT.

The patient is scheduled for the procedure the following week.

Rationale

There are multiple conditions identified in this example, including HSV, history of NMSC, and AK. However, the encounter is centered around the multi-year history of AKs despite previous treatments to resolve these lesions.

• The American Medical Association (AMA) considers a problem to be addressed when it is evaluated or treated by a dermatologist or non-physician clinician (NPC) at the time of the encounter.

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

• Further, the AMA defines a chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression that requires additional supportive care as a chronic illness with exacerbation and is categorized as a problem addressed at the moderate level.

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

The level of risk of patient management options in this encounter involves the decision for a minor surgery (procedure) with identified risk factors scheduled at a later date. Photodynamic therapy, which does not have an associated global post-operative period, is classified as a minor procedure for the purposes of MDM. The distinction between a major and minor procedure for the purposes of MDM takes into account multiple considerations, including global post-operative period. However, this distinction is not based solely on the presence, absence, or length of the global post-operative period.

• The AMA does not define minor or major procedures by its associated global surgical package. However, CMS classifies minor and major procedures based on the global surgical package relative to number of post-operative days assigned to the CPT code. (Minor; 0-10 days post-operative period and Major; 90-day post-operative period). Check with your private payers for guidance regarding their classification of minor versus major procedures.

• The AMA indicates that a minor surgery (procedure) with identified patient or procedure risk factors is at the moderate 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 of possible HSV reactivation, the level of risk of patient management is at the moderate level of risk for this MDM element.

Clinical vignette 27

A 75-year-old male follows up for severe actinic damage. At most visits over the last few years, you decide together which lesions require cryotherapy or curettage for treatment, and which can be treated topically. Since his last visit he has used topical 5-fluorouracil cream twice daily for 2-3 weeks on his forehead and temples and has noticed resolution of these lesions. The patient is satisfied with the results and no further treatment is necessary at this time.

He has, however, developed 8 new tender, rough spots on his scalp, ears, and the backs of his hands. You agree that these lesions are new actinic keratoses and discuss treatment options including photodynamic therapy, cryotherapy, or additional topical therapy with 5-fluorouracil.

He opts for continued topical therapy, and you review appropriate use and expectations of 5-fluorouracil.

Rationale

In this example the previously treated actinic damage of many years has resolved and would be considered a stable chronic illness if not for the presentation of new actinic lesions. As such, the problem addressed in this example is a chronic illness with exacerbation or progression.

• The AMA defines a chronic illness with exacerbation as one that is acutely worsening, poorly controlled or progressing with an intent to control progression that requires additional supportive care a problem addressed at the moderate level.

• Per the AMA, addressing a problem includes consideration of further testing or treatment options that may not be selected based on risk versus benefits analysis or the choice of patient, guardian, or surrogate.

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

The level of risk of patient management in this example involves discussion of the risk and benefits of various treatment options as well as expected results in treatment of the lesions with prescribed topical prescription.

• Based on the AMA’s guidelines, in addition to direction on the use of prescribed medications, prescription drug management includes a discussion of risks, benefits, and alternatives of the prescribed treatment.

As discussion with the patient of risks, benefits, and alternatives of this prescribed treatment was documented, meeting this MDM element is categorized as a moderate level.

Clinical vignette 28

A 60-year-old female hairdresser presents with significant actinic damage, numerous actinic keratoses on the face. In addition, this patient has a solitary actinic keratosis on the left dorsal hand without significant attendant background actinic damage, and the right dorsal hand is clear.

During the detailed discussion of the planned 5-flourouracil topical therapy, the patient notes that it would be “impossible” to have their hands out of commission due to this therapy, and also is concerned that wearing gloves would be “off-putting” to their clients. You are concerned about occlusion issues with the use of gloves.

During joint decision making of the treatment plan, including discussion of the risk and benefits of each treatment option, it was decided to treat the face with topical 5-flouracil, a prescription was sent to the pharmacy, and the solitary left hand actinic keratosis is treated with cryotherapy.

Rationale

In this example, the lesion on the hand was evaluated as part of a component of the minor procedure performed during the encounter, and therefore is not considered when determining the complexity of the problem addressed for the level of E/M service reported.

• In general, the decision to perform a minor surgical procedure is bundled into the surgical package and included in the payment of the minor procedure.

• To determine if an E/M service can appropriately be reported with a minor procedure, one must not consider any information related to the concurrently billed procedure performed.

Removing the lesion on the hand from this encounter, the problem addressed is the actinic damage and keratoses on the face. As the medical record does not include documentation that the problem addressed during this encounter fulfills the criteria of chronic condition, the AK lesions are categorized as an acute uncomplicated illness.

• The AMA defines a problem that is recent with low risk of morbidity for which treatment is considered an acute uncomplicated illness or injury.

Although the medical record indicates a concern for field cancerization, the record does not confirm that field cancerization is currently present nor addressed or managed during the encounter.

• The AMA defines a problem address or managed as one that is evaluated or treated at the encounter.

Therefore, the problem addressed for this example is considered one addressed at the low level for this MDM element.

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

The risk of patient management options focused on the treatment of the AKs on the face includes discussion of the risks and benefits of treatment by topical therapy, meeting the requirements of prescription drug management, and thus supporting a moderate level of risk for this MDM element.

The patient management options discussed during the encounter related to the decision to perform cryotherapy on the lesion on the hand is included as a component of the procedure performed and is not considered in the determination of the level risk of patient management.

As a separately identifiable E/M encounter was performed, both the E/M appended with modifier 25 and the cryotherapy performed during the encounter are reported for this example.

Clinical vignette 29

Your patient presents scaly bumps on the scalp, face, and arms. She has had these bumps for 3 years, but they have recently become larger and seem to have multiplied. While she has no personal history of skin cancer, there is a family history of basal and squamous cell carcinomas. The patient is on apixaban for atrial fibrillation.

You perform a complete skin exam, and diagnose her with actinic keratoses, photodamage, and suspected squamous cell carcinoma.

You discuss treating the actinic keratoses with a topical 5-fluorouacil including the risks, benefits, and alternative medications. You also discuss photodamage mitigation strategies and surgical excision of the possible carcinoma. You also discuss that surgery is associated with multiple risks, including bleeding, infection, and scar. The benefit of continuing on anticoagulation despite concerns about post-operative bleeding and bruising is reviewed and the patient is advised not to discontinue her medications.

Rationale

The problems addressed during this encounter include actinic keratoses that are worsening, considered a chronic illness with exacerbation and a suspected squamous cell carcinoma which is categorized as an undiagnosed new problem with uncertain prognosis. Either of these problems meet the criteria for a problem addressed at the moderate level.

The AMA has clarified that other than what is specifically stated in the categorization of problems addressed in the MDM table, summing up of problems is not allowed.

There is no data to be reviewed or analyzed (Straightforward).

The risk of patient management includes multiple treatment options, including discussion regarding a minor procedure with identified patient or procedural risk factors (moderate) and prescription drug management (moderate).

• The AMA has clarified 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.

• The AMA indicates that a minor surgery with identified patient or procedure risk factors is at the moderate level of risk. Identified patient or procedural risk factors are those risk identified in the medical record that are above and beyond those typically associated with the procedure.

• 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.

As the highest level of risk of patient management options is moderate, the level of MDM for this element is moderate. Two of the three MDM elements have been met therefore the appropriate MDM level is Moderate.