# New Patient skin check



## dixiesheppick (Sep 19, 2014)

Ok seasoned Derm coders- This patient has a hx of melanoma, but absolutely nothing today. HPI is doesn't have much... My doc thinks he should get a 99203, I am thinking 99201? How would you code it? 

Chief Complaints: 
    1. NP skin check .  

 HPI: 
   New symptom(s):  
       pt has hx of melanoma T1A on the lt shoulder; here for a full skin exam; no new moles or changing moles today. 

 ROS:  
   Dermatology:  
       Systemic Negative.  Head Negative.  Lumps under the skin (nodes) Negative.  Eyes Negative.  Ears, Nose, Throat Negative.  Heart Negative.  Lungs Negative.  Digestive Negative.  Genitourinary Negative.  Menstrual Cycle Negative.  Bleeding Problems Negative.  Musculoskeletal Negative.  Neurological Negative.  Psychological Negative.  Skin (besides primary reason for coming Negative.     


 Medical History: hx melanoma T1A.  

 Medications: None 

 Allergies: N.K.D.A. 


Objective:

 Examination: 
   General Examination: 
       GENERAL APPEARANCE: healthy appearing, pleasant, NAD. 
       NEUROLOGIC: alert and oriented. 
       PSYCH: mood/affect appropriate.      
   Dermatology: 
       SCALP: within normal limits. 
       FACE: within normal limits. 
       EYELIDS: within normal limits. 
       LIPS: within normal limits. 
       NECK: within normal limits. 
       CHEST: within normal limits. 
       ABDOMEN: within normal limits. 
       BACK: within normal limits. 
       R UPPER EXTREMITY within normal limits. 
       R HAND/FINGERS within normal limits. 
       L UPPER EXTREMITY lt medial deltoid scar with no obvious recurrance. 
       L HAND/FINGERS within normal limits. 
       L LOWER EXTREMITY within normal limits. 
       R LOWER EXTREMITY within normal limits.      



Assessment:

 Assessment: 
1. History of melanoma - V10.82 (Primary)   

Plan:

 1. History of melanoma 
Notes: continue to observe; watch for black in moles; wear sunscreen daily.


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## CatchTheWind (Sep 23, 2014)

I get a 99201.  Here's how:

History: PROBLEM-FOCUSED (1 HPI element (location), 7+ ROS elements, no PFSH)
Exam: DETAILED (12+ elements)
MDM: STRAIGHTFORWARD (I get 1 problem point for the history of melanoma as a "resolved, stable, or improving problem."  There are no data points.  Risk level is ambiguous, as CMS's examples don't take into account (as far as I know) monitoring for recurrence of previous diseases.  So I'd be conservative and give it 1 point for risk.)


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## dixiesheppick (Sep 27, 2014)

Thanks, that is what I got, it's good to have the validation. One more question... I know this one is pretty basic, but the way that he documents has me questioning this HPI. I have always learned, that HPI needs to be something active going on. Can you count Associated signs and Symptoms: not painful or quality: doesn't bleed? I don't think you can. Please let me know, what you would count. Thanks again.

Chief Complaints: 
    1. NP- Possible Cancer.  

 HPI: 
   New symptom(s):  
       history of precancers treated in past
       Location: face
       Duration: long time
       Symptoms: not painful
       Quality: doesn't bleed
       ==================
       location: lt deltoid
       symptoms: not painful
       quality: dry, doesn't bleed
       duration: couple of years
       ==================
       location: rt shoulder
       duration: 3 months


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## abhobson@yahoo.com (Nov 20, 2014)

*Q4100*

Having issues receiving payment from BCBS Medicare and traditional Medicare for the EZ Derm Porcine Xenograft (Q4100) that is applied after Mohs surgery. Medicare was paying and now they state the code does not match its product. I have sent numerous appeals with the packaging information and the product label. I was told by BCBS to use Q4136 however they've paid us pennies.....

Is there anyone who has any suggestions or has had similar problems? I don't know what else to try.


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## CatchTheWind (Nov 21, 2014)

This is in reply to dixiesheppick's question: If I understand you correctly, you are asking whether you can get HPI points for quality and so forth when the chief complaint is a "history of."

I have always counted them, but now that you bring it up, it's a good question.  Does anybody know for sure?


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## arrana (Mar 4, 2015)

I would use 'history of..." as context in HPI, so yes, I would count it.

Hope that helps.

Arrana


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## CatchTheWind (Apr 22, 2015)

Sorry to be picking this up so belatedly.  Arrana, you made a very good point that "history of skin cancer" could count as context when the current complaint is a suspicious lesion!

I read dixiesheppick's question to mean whether the details of the historical cancer (Location: face, Duration: long time, Symptoms: not painful, Quality: doesn't bleed) can count as location, duration, etc.  I count them because "history of skin cancer" is an actual chief complaint (V10.82/V10.83).  But I have never seen any documentation that this is okay.


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## JesseL (Apr 22, 2015)

doesn't the "pt has hx of melanoma" part count as part of PFSH?


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## CatchTheWind (Apr 23, 2015)

I think that would be double-dipping, since it is also the HPI, but you do have allergies and meds.  I somehow missed those the first time around!


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