Dermatology Coding Alert

Answer 1: You should bill the scenario based on the appropriate level of E/M service (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient).

Note: If you want to bill based on time, the dermatologist must spend more than 50 percent of the total face-to-face time counseling and/or coordinating care with the patient. If your dermatologist's encounter does not meet this requirement, you cannot bill based on time.

Extra: You also cannot bill based on time if the physician states that a communication barrier extended the face-to-face time with the patient. Communication barriers do not meet the counseling/coordinating care criteria. 

The dermatologist may document the excessive effort of trying to get an appropriate history, with the reason for excessive effort and why he was unable to obtain the full history. He may receive credit for the "unobtainable" history.

Warning: If the dermatologist reports service time when the patient is not physically present, you cannot report this time to most payers, says Jeffrey Weinberger, MD, director of the clinical research center in the department of dermatology at St. Luke's Roosevelt Hospital Center and assistant professor of dermatology at Columbia University in New York City.

Payers consider extra time, as noted in the example above, part of the pre- and postservice work associated with the payment for the E/M service. 

If you submit a charge for this extra time to a payer that  does not cover the service, the carrier may hold the patient responsible for the fee. 

Answer 2: As long as the physician signs the nurse's notes and documents that he reviewed them, you can meet the requirements for ROS and PFSH with information from the nurse's notes, Weinberger says. You'll use ROS and PFSH, along with the patient's physician-documented HPI, to decide the level of information the dermatologist gathered about the patient's history.

The ROS is basically an inventory of the body so the dermatologist knows where to direct the physical examination. The inventory may include evaluations of any of the following systems or parts: allergic/immunologic, cardiovascular, constitutional symptoms, ears/nose/mouth/ throat, endocrine, eye, gastrointestinal, genitourinary, hematologic/lymph, integumentary, musculoskeletal, neurological, psychiatric, and respiratory.

For a problem-pertinent ROS, the physician needs to review a single system or part, and will usually follow the guidelines of E/M codes 99202 (Office or other outpatient visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making) or 99203 (... a detailed history, a detailed examination, and medical decision-making of low complexity).

If the dermatologist reviews two to nine systems, you should consider the ROS "extended," which means it usually translates to 99203. If he considers at least 10 systems, the ROS is "complete," which may earn a 99204 (... a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity) or 99205 (... a comprehensive history, a comprehensive examination, and medical decision-making of high complexity).

A "pertinent" PFSH consists of a comment in any one of the histories - information about a patient's past health history, family history, or social history - and earns a 99203. For a "complete" PFSH, the physician must have information that involves all three of the histories. The complete PFSH translates into 99204 or 99205.

Answer 3: Ask your dermatologist if the past medical/surgical history constitutes an ROS. Show him the CPT guidelines and have him clarify what he believes to be an ROS.

The CPT guidelines state that the past medical history indicates a patient's past experiences with an illness or injury. But, in contrast, an ROS is an inventory of questions based on the history of the patient's presenting illness.

The answers to the ROS questions determine the type and extent of the exam the dermatologist conducts. Answering the inventory questions can provide the physician with the past medical history. Encourage your doctor to indicate the systems reviewed and record the positive and pertinent negatives for each system addressed.

Answer 4: CPT states that the ROS is "an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced." The documentation of the bicycle accident doesn't fit this definition and is more consistent with CPT conception of past history, which is a review of the patient's past experiences with illnesses, injuries and treatments. Therefore, the dermatologist could consider the comment part of PFSH, Weinberger says.

Extra: If documentation supports medical conditions that are pertinent to the patient's present condition (that is, hypertension in a patient who has chronic obstructive pulmonary disease), some carriers allow you to assign this as part of the ROS (since it impacts the patient's condition), while others only allow you to count it toward a PFSH.