# To Bundle or not to bundle and procedure ?s



## sparkles1077 (Oct 8, 2014)

Hello Fellow Coding Professionals,

Tryin to tackle some dermatology here.

I am wondering what are the documentation requirements for 17111?  Is the provider required to state the location and number of lesions?  This is what the provider documents:  
Flat topped verrucous papules (vs stuck on or waxy papules) on bilateral upper extremities, r lower extremity and digits on hands - contagious nature and options for treatment discussed - below chosen = #>15 verruca(e) and suspected verrucae (vs SKs) treated with liquid nitrogen - sequelae discussed.
Is this sufficient for 17111?  Or do we need to see the number of lesions per location?

*To bundle or not to bundle:*

CC:  Skin Lesion Check  consult from Dr. Blank for bleeding lesion on abdomen there since had sting in 2007 and 1 month ago it bled in shower, also bled about 2 weeks ago when was at doctor's office without known trauma.
Case 1
HPI- consult as above.  Skin check.  Mole on back there for years - was red - changes per his wife.

Patient Active Problem List
  Irritable bowel sundrome
  Low serum testosterone level
  Family history of skin cancer - maternal grandmother

Review of Systems:
  Skin:  as above
Allergies
Allergen
  Sertraline Hcl
    faint
Objective:  Well appearing 39 year old male in NAD.  Normal mood and affect.  Skin exam was performed including scalp/hair (inspection and palpation).  Normal from skin cancer or reason for visit perspective except as noted.  A) R abdomen - 3 mm erythematous papule with collarette of scale.  Shave removal - site (s) a) prepped with alcohol pad then anesthetized with 1% lidocaine with 1:100,000 epinephrine after verbal consent obtained - shave removal (since bothersome) with razor blade - electrocautery applied for hemostasis and additional destruction - polysporin pint and bandage applied and post-op wound care discussed - no complications.  Back brown papule with cherry angioma at surface.

A/P Blank was seen today for skin lesion check.

Diagnoses and associated orders for this visit:

*Unspecified disorder of skin and subcutaneous tissue
   comments:*  a) pyogenic granuloma vs hemangioma
                   - SURG PATH, LEVEL IV
                   -SHAVE SKIN LES <5 MM TRUNK, ARM, LEG
*Family history of skin cancer* - maternal grandmother
*Benign neoplasm of skin of trunk, except scrotum*
Nevus back - watch
   (offered biopsy since changed but not clinically concerning)
*Cherry angioma*
*Bleeding:*
    - SURG PATH, LEVEL IV
     -SHAVE SKIN LES <5 MM TRUNK, ARM, LEG

Sunscreen, hat, skin self exam monthly stressed
f/up pen or 1 year.  Reassured about: benign diagnoses

Provider Codes:  99243-25, 88305, 11300

My Codes:  99242, 11300  Would some see the E and m as bundled?

Consult requirements are met,  88305 is ordered but there is no interpretation (it looks like it was sent out),  No mod 25 required for new patient visits

Case 2:
CC:  Skin Lesion check  
       spots on back
HPI- new pt self referred for above lesions which are not extremely itchy, painful, bleeding,growing recently or getting caught on things.  Skin tag R thigh bled after picking.  Skin check.  PCP is Dr. Blank.

Patient Active Problem List
   History of basal cell carcinoma
   Personal history of prostate cancer
Review of Systems:
   Skin:  as above
   No Known Allergies

Objective:  Well-appearing 60 year old male in NAD.  Normal mood and affect.
Skin exam was performed including scalp/hair (inspection and palpation), head/face, conjunctiva/lids, lips, neck, chest/axillae, abdomen, back, bilateral upper extremities, bilateral lower extremities (except areas covered by shoes/socks and shorts (but R thigh examined), digits/nails(inspection and palpation).  Normal from skin cancer or reason for visit perspective except as noted.  Snip removal of acrochordon(s) - site(s) R thigh prepped with alcohol pad then anesthetized with 1% lidocaine with 1:100,000 epinephrine after verbal consent obtained - snipped with scissors - aluminum chloride applied for hemostasis - ointment and bandage(s) applied, as necessary, and post-op wound care discussed - no complications - # acrochrodons removed = 1.  Erythematous, scaly papule(s) vs scaly papule(s) vs Macule(s) vs Plaque(s) (seborrheic keratosis/es) on back.

A/P Blank was seen today for skin lesion check.

Diagnoses and associated orders for this visit:

Other seborrheic keratosis
   comments: declined cosmetic removal

Actinic Keratosis
  -DESTRUC BENIGN/PREMAL 1ST LESION
  -DESTRUC BENIGN/PREMAL,2-14 LESIONS
  declined efudex (potential cost)

Unspecified hypertrophic and atrophic condition of skin
 -REMOVAL OF SKIN TAGS, 1-15

History of basal cell carcinoma

Reassured re:  benign diagnoses
Sunscreen, hat, skin monthly stressed
f/u one year

Provider Codes:  99203-25, 17000, 17003 x 11, 11200
My codes:  99202, 17000, 17003 x 11(ICD9:  702.0), 11200(ICD9:  701.9, 782.0)
                Would some see the E and M as bundled? Or would you credit for skin check?

Case 3:
CC:  Skin lesion check
       spot on nose getting largely lately, where glasses hit
HPI:  established pt R arm lesion not extremely, itchy, painful, bleeding, growing recently or getting caught on things.  Other spot on nose not extremely itchy, painful, bleeding, growing recently or getting caught on things.

Patient Active Problem List
  Hypertension
  History of CVA
  Depressive Disorder, NEc
  Esophageal reflux
  Actinic keratosis

Review of Systems:
Skin:  as above
No known allergies

Objective- Well-appearing 68 year old female in NAD.  Normal mood and affect.  Stuck on vs waxy papule vs plaque (seborrheic keratosis/es) on nose and verruca R arm - 1 sK on nose and 1 verruca R arm treated with liquid nitrogen - sequelae discussed.  Milium vs come do on nose.

A/P Blank was seen today for skin lesion check.

Diagnoses and associated orders for this visit:

*Other seborrheic keratosis*
   Comments:  bigger recently
   DESTRUC MILI, MOLLUSCUM, 1-14 L
*Viral warts, unspecified*
  DESTRUC MILIA, MOLLUSCUM 1-14 L
otc freezing agent or salicylic acid if not resolved
*Unspecified disorder of skin and subcutaneous tissue*

Reassured re:  benign diagnosis/es
Sunscreen, hat, skin self exam monthly stressed
fu May

Provider Codes:  99213-25, 17110
My Codes:  17110  I see E and M as bundled.  Any thoughts?

Thank you in advance for your assistance!


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