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Dermatology Coding Alert

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Make Your E/M Visit Documentation a Snap

Published on Sat Sep 11, 2004

If you want to nail the correct E/M code every time, the template below, created by our experts for dermatology practices, includes all the essentials for perfect documentation.

Single Organ System Exam Integumentary

Constitutional

 

  • The physician measures any three of the following  seven  components:

    Vital signs:
     1. sitting or standing blood pressure
     2. supine blood pressure
     3. pulse rate and regularity
     4. respiration
     5. temperature
     6. height
     7. weight (may be measured and recorded by ancillary staff)

     

  • General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming).

    Exam

     

  • Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, pubic area (when indicated) and extremities
     
  • Inspection and/or palpation of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers, susceptibility to and presence of photo damage) in four of the following five areas:

     1. head and neck
     2. chest, breasts and back
     3. abdomen
     4. genitalia
     5. extremities
     
    Don't miss: For the comprehensive level, the examin-ation of at least eight anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissues of the head and neck and extremities constitutes two areas, such as: inspection for eccrine and apocrine glands of skin and subcutaneous tissue with identification and location of any hyperhidrosis, chromhidrosis or bromidrosis.

    Note: CMS explains this template (http://www.cms.hhs.gov/medlearn/master1.pdf) to help you confirm that your documentation meets the criteria to code your E/M services to the highest and most appropriate level.

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