Coding Checklist: Answers to Actual Coding and Documentation Queries

Here are accurate responses to a round-up of questions from dermatology practices.

By Sharon Andrews, RN, CCS-P

Questions about coding arise in every medical practice. Our clients often turn to DermResources when they need coding clarification. In efforts to address concerns you may have, following are coding questions we’ve fielded recently.

If I note in the record, “patient complains of lesion on his face,” is that one HPI or two? Do I have to include the description, “crusty lesion” to have two HPI?

“Lesion” is the complaint, so it cannot be used as part of HPI. Face is the location, thus, satisfies one element of HPI. “Crusty” would be associated signs and symptoms, another element of HPI. This is rather insignificant though, because the requirements for HPI are one to three (in which one is enough) or four or more, depending on the level of history required.

Do pertinent negatives, such as “no complaints of fever or chills,” “denies history of skin cancer,” “no previous treatment,” or “left lower extremity within normal limits,” count for HPI?

Documented negative responses to questions of HPI, ROS, Past, Family, Social History or physical exam findings qualify. The idea is for the treating clinician to learn what he or she needs to know to treat the patient appropriately. As long as it is medically necessary to ask those questions or examine those areas, negative answers have the same value as positive ones.

The CMS guidelines indicate that when one system is reviewed it must be problem-pertinent. If additional systems are reviewed, do they also have to be problem-pertinent?

CMS provides no further guidelines on that subject. However, it is generally best to be able to demonstrate the medical necessity of all the work you do for a patient, whether it be ROS or other history, exam, tests ordered, etc. When you can demonstrate medical necessity you should not have to fear an audit.

Our practice has a policy requiring all biopsy patients to have a follow-up visit to receive results. Is there any way this could be considered fraud?

Biopsies have no follow up days, so there is no problem in that regard. However, for all visits for which you charge you must be able to demonstrate medical necessity. If biopsy results show some condition that the physician feels must be discussed with the patient in person or the patient must be brought back for treatment, I see no problem.

However, an auditor reviewing a number of records and seeing patient after patient coming back for an appointment to hear that the biopsy was normal would question why those reports could not have been communicated by phone. Some physicians argue that it is necessary to examine the surgical site to assure that there is no infection. However, infections following biopsies in otherwise healthy patients are rare. Written postoperative instructions given to the patient should include warning signs of infection and instruct the patient to call the office if any of those signs are noted.

There will always be a few patients who are more susceptible to infection or have no one in the household to observe the surgical site, factors that would demonstrate the medical necessity of the follow up visit. Ultimately, each patient must be considered individually.

Is it appropriate to use CPT code 67850 when using liquid nitrogen to destroy an AK on the eyelid?

The CPT definition for this code specifies lid margin. So if the lesion is on the margin, the code is appropriate. If it is just on the skin of the eyelid, use 17000.

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Coding Checklist: Answers to Actual Coding and Documentation Queries

Here are accurate responses to a round-up of questions from dermatology practices.

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