Dermatology Coding Alert

Question: The E/M guideline chart that we use to select the history level includes identifiers. For example, to report a problem-focused history, documentation should show a brief history of present illness (HPI), no review of systems (ROS), and no past, family and/or social history (PFSH).
 
What should we do if the levels of HPI, ROS and PFSH don't match the chart? How should we determine the levels?


Texas Subscriber

Answer: You should select the level of history according to the elements present in the dermatologist's documentation (HPI, ROS, PFSH). The components must meet all of the requirements for a specific level for you to submit a claim for that level. If the patient lacks one of the elements, your choice depends on the element the chart is missing.

In other words: If the history qualifies for level 99212, the exam is level 99213, and the MDM is level 99212, then the office visit is a level 99212. You must choose the lowest of the two or three components.

Example: A detailed history requires a minimum of four HPI elements (or the status of three or more chronic conditions when using 1997 guidelines), a review of at least two systems (ROS), and a comment about one of the "histories" (past, family or social) from your allergist.

If the dermatologist comments about only one ROS, the documentation does not support the requirements for a detailed history. Therefore, you should select an expanded problem-focused code that corresponds to the history requirements for 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) because the dermatologist has met ROS requirements for this level (one to three HPI elements, one ROS, zero PFSH).