# E/M based on time: medical necessity



## hkatie (Feb 7, 2013)

I would appreciate any feedback on the following note for a new patient. My provider has asked for a 99202, which is problematic for a couple of reasons. I am mostly concerned that the patient and provider mixed a cosmetic services consultation into a medically necessary services visit and now we are lacking enough information in the note to tease out one from the other. (And I do know that the 15 minutes is insufficient for the 99202 even if everything else was kosher, but this is a perfect example of a larger problem we sometimes have in derm: the line between medically necessary treatment of rosacea and cosmetic treatment. The do NOT overlap, but it can feel like they do when the note is said and done. Really, this is an opportunity to get second opinions on this issue in general from other coders).

Thanks in advance for slogging through the note and any input on how my provider can address visits like this in the future.

"Chief Complaints:
1. Skin Lesion
2. Rosacea
HPI: This is a 62 year old female who:
1. comes in for a chief complaint of a skin lesion, located on the lip. The lesion is asymptomatic. The lesion has been present for months. This lesion has not been treated in the past. The patient presents today for: further evaluation and management.

2.comes in for a chief complaint of rosacea, located on the face. The rosacea presents with flushing and enlarged pores and is moderate in severity. The rosacea has been present for months, and occurs in the context of the following triggers: exercise. The patient has taken the following treatments in the past: no treatment. 

Derm History:
Rosacea
Blistering Sunburns

Medications: hydrochlorothiazide, lisinopril, lorazepam
Allergies: No known drug allergies

ROS: A focused reviewof systems was performed including Cardiovascular, Constitutional / Symptom, Hematologic / Lymphatic, and Integumentary and was notable for general health good. No new skin lesion, no rash, no new lumps or bumps, and no  blood thinners.

Exam: An exam was performed including the head (including face). 

Impression/Plan: 

1. Venous Lake: violaceous papule located on the inferior vermilion lip. Plan: Counseling.
I counseled the patient regarding the following: Skin Care: Venous Lake can resolve with lasers or electrodesiccation. Expectations: Venous Lakes are benign vascular growths. No treatment is necessary. Can be removed by vbeam laser $150/tx Plan: Reassurance.

2. Telangiectatic Rosacea: centrofacial erythema and telangiectasia distributed on the face.
Plan: Counseling. I counseled the patient regarding the following: Skin care: Patient instructed to wear sunblock. Moisturizers with green tints can hide redness. Expectations: Rosacea is chronic. Flushing and pimples can be triggered by: alcohol, stress, exercise, hot temperatures or spicy foods, wind and sun exposure. Telangiectasias can be improved with laser. Contact office if: Rosacea worsens or fails to improve despite months of treatment; patient develops nodules or cysts. Plan: Defer. The following procedure was deferred: IPL - face. Reason for Deferral: needs to schedule a separate appointment. Instructions: Elos: $400 full face.

3. Static Rhytides: prominent deep folds located on the glabella. Plan: Counseling.
I counseled the patient regarding the following: Skin care: Sun block and topical retinoids are the best preventative measure against photoaging. Fine static rhytides can be treated with medium depth chemical peels, non-ablative or ablative infrared lasers. Deep folds can be lessened with fillers. Expectations: Static Rhytides are wrinkles in the skin that form from skin laxity and sun damage. Without cosmetic intervention, rhytides are permanent forms of aging. Contact office if: patient is interested in pursing a cosmetic procedure.

Follow up PRN. 10 minutes for *Skin Check

15 minutes of face to face time with the patient, of which 80% of my time was spent counseling."

Thanks so much,

Katie


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## debflutter (Feb 7, 2013)

This should be coded as 99201.  Once they document the time with the counseling or coordination of care, you're obligated to code by that


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## hkatie (Feb 7, 2013)

debflutter,

Thanks for your feedback. How would you address the issue of separating out medically necessary counseling from cosmetic services counseling?

Thanks,

Katie


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## OCD_coder (Feb 8, 2013)

Just making an observation as it would be noted on an external audit for a possible compliance risk.  There is conflicting information upon closer review.  How can you have 80% time spent counseling when 10 of the 15 minutes are performing the exam?  Doesn't that come to 33% time spent counseling/coordinating care when you break down the math?  


_"10 minutes for *Skin Check "_   = exam


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## hkatie (Feb 10, 2013)

Hi Michelle,

Thanks for your input. That notation of "10 minutes" is actually an instruction for the follow up appointment scheduling, not documentation of how long the exam took on this particular date of service. It's easier to see when viewing the original formatting of the note rather than my choppy scrub job here.

What I'm stiil hoping for is anyone with some experience working with providers on documenting visits like this more clearly so that an auditor will not need to throw out the baby with the bathwater. In real clinical life, derm patients often don't know that the issues they are presenting with and want dealt with are cosmetic. Some common examples we see:

Lines and wrinkles? Obviously cosmetic. 

A dark brown spot that developed on the arm over time? Maybe lentigo, maybe lentigo maligna... Evaluation of either is fine. Removal of one is not medically necessary. Removal of the other is essential. 

Painful, enlarged acne cyst on the skin? Medically necessary to treat. The resulting scar? Not medically necessary to correct. 

Treatment of telangiectasias resulting from the rosacea process? Cosmetic. Treating the underlying cause (i.e. the rosacea itself)? No problem.

Possibly I should have posted this over in the Derm forum, but I was hoping for input from some of the stronger E/M coders we have on the board on how to help my providers appropriately document and bill these situations. I guess I'm also just looking for gut reactions from coders when they read the note. Did your HS detector go off?

Thanks,

Katie


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## Karolina (Feb 11, 2013)

Hello:

If the time is hard to figure out due to the mix of medically necessary and cosmetic components I would code this out based on the elements. I never heard that one must code time based when time is stated. In this case based on the elements supporting medical necessity I see a detailed history, a problem focused exam, and a low MDM. It is a 99201, because there is only 1 exam item listed (unless the actual note has more detail). If the exam is EPF, then 99202 is supported. I have excluded the obviously cosmetic components from the analysis.
Hope this is useful.


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## hkatie (Feb 12, 2013)

Karolina,

Thanks for your input. It is much appreciated.

Katie


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