Coding questions answered.
Q: I have a coding scenario that is confusing for me, so I would like your input.We had a 62-year-old established male patient who came in for his annual skin exam due to a personal history of squamous cell carcinoma (SCC) on the left cheek that was removed two years ago. The patient didn’t have any new concerns on his recent visit other than a few scattered brown spots on the trunk.The provider identified those as being benign nevi and seborrheic keratoses. A complete skin examination is performed, and diagnoses for the visit included benign nevi on the trunk, seborrheic keratoses, and his history of SCC. Sun protection, including the use of SPF 30 or higher sunscreen, and self-skin exams are recommended treatments. What would the correct evaluation and management (E/M) level for this service?
A: In addition to the history of skin cancer: The patient presents with two or more self-limited minor problems (benign nevi and seborrheic keratoses), which qualifies this element as low complexity.It is recommended that the patient use over-the-counter (OTC) broad-spectrum sunscreen, which qualifies the risk of complications and/or morbidity or mortality of patient management as low.
Based on these documented elements, the appropriate E/M code level to report would be 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 time for code selection, 20-29 minutes of total time is spent on the date of the encounter. Since time wasn’t included, 99213 is supported based on medical decision making, as two of the three elements (i.e., problems and risk) meet the low-level MDM.