Internal Medicine Coding Alert

Question: A patient with a history of skin cancer presented for a total body skin check. The physician noted no tumor, but one potentially pre-cancer lesion. What code should I report for the visit and diagnosis?

Wyoming Subscriber

Answer: Code the encounter with an appropriate E/M code reflecting the level of history, exam, and medical decision making involved. Use a relevant diagnosis that identifies the pre-cancer lesion (such as 702.0, Actinic keratosis) as the primary diagnosis and either V10.82 (Personal history of other malignant neoplasm of other sites; Malignant melanoma of skin) or V10.83 (Personal history of other malignant neoplasm of other sites; other malignant neoplasm of skin) as a secondary diagnosis.

Remember: Many insurance carriers do not like screening V codes with a problem-oriented E/M code, so you should use them as primary diagnoses when your internist finds no other diagnosis. Also, make sure you indicate in your report that the patient has a history of skin cancer and note, if possible, what kind of skin cancer it was (such as BCC [basal cell carcinoma] or SCC [squamous cell carcinoma]).