Coding for preventive skin examination in 2021 and beyond
To understand the new evaluation and management (E/M) coding guidance, the AAD/A recommends reviewing and applying the coding guidelines holistically. When coding is based on medical decision making (MDM), documentation for the encounter must meet or exceed two of the three elements as described in the E/M Office Visit Level of MDM Table (PDF download) namely:
Number and complexity of problems addressed
A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.Amount and/or complexity of data to be reviewed and analyzed
Data are divided into three categories:Tests, documents, orders, or obtaining information from someone other than the patient.
(Each unique test, order, or document is counted to meet a threshold number).Independent interpretation of tests.
Discussion of management or test interpretation with external physician or non-physician clinician (NPC) or appropriate source.
Risk of complications and/or morbidity or mortality of patient management
The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk.
The table below provides further clarification of the definitions for the MDM elements:
American Medical Association (AMA) definitions for the 2021 MDM elements
| Element | AMA definition | Additional information |
|---|---|---|
|
Number and complexity of problems addressed |
AMA defines a problem as addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being “addressed” or managed by the physician or non-physician clinician (NPC) reporting the service. Referral without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or NPC reporting the service. |
Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. |
|
Amount and/or complexity of data to be reviewed and analyzed |
Data includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or interprofessional communications and interpretation of tests that are not reported separately. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter. Assessment requiring an independent historian(s). |
External records, communications and/or test results are from a physician, NPC, facility or health care organization not affiliated with the dermatology practice. Tests are imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel e.g., lipid panel test [80061] for a patient on isotretinoin is a single test. The determination between single or multiple unique tests is defined by the CPT code e.g. cholesterol [82465], triglycerides [84478] and quantitative human chorionic gonadotropin (hCG) (84702) would each be counted as an individual tests when they are not performed as part of the lipid panel. *Do not separately bill the interpretation and/or report of results of tests ordered by the dermatologist or NPC. The interpretation of test results should be documented in the medical record. An independent historian is an individual other than the patient or physician who provides a history because the patient is unable to provide a complete or reliable history or because the dermatologist or NPC determines that a confirmatory history is necessary. |
|
Risk of complications and/or morbidity or mortality of patient management |
Patient management decisions made during the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered but not selected, after sharing the MDM with the patient and/or family. |
For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization. |
How to apply the three MDM elements
To understand how to apply the three MDM elements, review the following examples.
Example #1: An established patient presents for his annual skin examination pursuant to a history of basal cell skin cancers, squamous cell skin cancers, and melanoma. A complete skin examination is performed. No other concerns are identified today. Sun protection, including the use of broad-spectrum SPF 15 (PDF download) or higher sunscreen and self-skin exams are recommended treatments. Patient is advised to follow up in one year or if he sees any changes.
What is the number and complexity of problems addressed?
As documented, the history of malignant neoplasm is not considered a current problem being addressed or treated. Based on how the E/M Office Visit Level of MDM Table (PDF download) identifies number and complexity of problems addressed, the history of these conditions when an associated active problem is not identified and managed does not meet the complexity of any category in the MDM elements. An active problem must be identified and reported as the primary diagnosis to support the medical necessity for the encounter. As presented, this encounter would be reported with Z85.xxx (history of malignant neoplasm), which ICD-10-CM guidelines consider a secondary diagnosis; when reported as a primary diagnosis, it may cause a claim denial by most payers.
Please check directly with your payer for specific coding guidance regarding the use of ‘history of’ codes when reported as a primary diagnosis.
Please note
A history of skin cancer without an associated active problem does not identify a problem addressed or treated as required to support the MDM element of amount and/or complexity of problems addressed.
The examination is performed to identify new lesions or other problems present. The example does not indicate that new lesions or any other problems were identified. As we understand the guidelines, the patient’s “history” and “examination” no longer plays a role in determining the level of service.
What is the amount and/or complexity of data to be reviewed and analyzed?
The example does not state that there was any data reviewed, which qualifies this element as minimal.
What is the risk of complications and/or morbidity or mortality of patient management?
The example recommends the use of over the counter (OTC) broad-spectrum sunscreen which qualifies for the risk of complications and/or morbidity or mortality of patient management as low.
Now, by combining these elements together one can determine the E/M level of service:
Chief complaint | Follow-up/skin screening examination |
Number of problems addressed | None (straightforward) [no active problems] |
| Amount of data reviewed | Minimal or None (straightforward) [no data reviewed] |
| Risk of patient management | Low (low) [OTC broad-spectrum SPF 15] |
Therefore, based on the elements documented in the medical record documentation, this encounter is reported with: 99212 (Straightforward) [two of the three elements meet the straightforward MDM level].
2021 E/M coding tool
Use the Academy's 2021 tool to help you select the most appropriate code.
Access the toolExample #2: 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 his history of SCC. Sun protection, including the use of SPF 30 or higher sunscreen, and self-skin exams are recommended treatment.
What is the number and complexity of problems addressed?
In addition to the history of skin cancer the patient in this scenario presents with two or more self-limited minor problems (benign nevi and seborrheic keratoses) which qualifies this element as low complexity.
What is the amount and/or complexity of data to be reviewed and analyzed?
The example does not state that there was any data reviewed, which qualifies this element as minimal.
What is the risk of complications and/or morbidity or mortality of patient management?
The example recommends the use of OTC broad-spectrum sunscreen which qualifies for the risk of complications and/or morbidity or mortality of patient management as low.
Now, by combining these elements together one can determine the E/M level of service:
Chief complaint | Spots on the trunk, follow-up/skin screening examination |
Number of problems addressed | Limited (low) [two self-limited or minor problems] |
| Amount of data reviewed | Minimal or None (straightforward) [no data reviewed] |
| Risk of patient management | Low (low) [OTC broad-spectrum SPF 15] |
Based on the elements documented in the medical record documentation, this encounter is reported with: 99213 (Low) [two of the three elements meet the low MDM level].
Time
Another option not using MDM to determine the level of service would be to consider “total time” for these encounters. The 2021 coding guidelines define Time as total time spent by the dermatologist or NPC dealing with the patient’s problem(s), whether or not counseling and/or coordination of care dominates the service. Time includes non-face-to-face services: pre-, intra- and post-service. Please note that the time spent by clinical staff is not included in the calculation of “total time.”
The coding guidelines have provided clear time ranges within the code descriptors. Determining the level of service can be based on time or MDM. Do not combine time and MDM to report an encounter. The documentation must include the concise time spent addressing the patient problem(s). Below is a table that illustrates the time ranges for each code level.
| New patient E/M code | 2021 total time | Established patient E/M code | 2021 total time |
|---|---|---|---|
99201 |
Code deleted |
99211 |
Time component removed |
99202 |
15 – 29 minutes |
99212 |
10 – 19 minutes |
99203 |
30 – 44 minutes |
99213 |
20 – 29 minutes |
99204 |
45 – 59 minutes |
99214 |
30 – 39 minutes |
99205 |
60 – 74 minutes |
99215 |
40 – 54 minutes |
Example #3: An established patient presents for his annual skin examination pursuant to a history of basal cell skin cancers, squamous cell skin cancers, and melanoma. A complete skin examination is performed. No other concerns are identified today. Patient is counseled on sun protection, including the use of broad-spectrum SPF 15 or higher sunscreen and self-skin exams are recommended treatments. Patient is advised to follow-up in one year or if he sees any changes. Total time spent in skin examination and discussion of preventive measures with the patient is 25 minutes.
Based on the total time spent by the dermatologist/NPC, this encounter is reported with: 99213 (20 – 29 minutes).
Additional Academy resources
See a recent DCC article on frequently asked questions regarding 2021 E/M coding.
Access the Academy's practice management resources on 2021 E/M coding.
Review recent DCC titles for a variety of useful articles on 2021 E/M coding.
