Ophthalmology and Optometry Coding Alert

Question: A patient returned for a six-month follow-up after undergoing a biopsy of his left eyelid. The patient reported he was fine and was not experiencing any pain, discomfort, or any new symptoms. The eyelid biopsy led to a diagnosis of squamous cell carcinoma, which a plastic surgeon took care of due to the delicate nature of the skin. I view this condition as being more serious than a self-limited or minor problem. Because of this, can I code this as a level-three evaluation and management (E/M) encounter?

Tennessee Subscriber

Answer: Not necessarily. While skin cancer affecting the eyelid may be a more serious condition than a self-limited or minor problem (defined by CPT^® as a “a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status”), the seriousness of the problem does not automatically equate to a higher level of E/M service.

The reason for this is because “two of the three elements … must be met or exceeded” for a given level of medical decision making (MDM) per CPT^®, and the number or complexity of problems addressed at the encounter is only one of those elements. Based on the information provided, your eye care physician had minimal or no data to review or analyze relating to the patient’s condition; the provider did not prescribe drugs to manage the patient’s condition; the provider made no decisions regarding surgery for the patient; and any treatment your provider is considering for the patient’s condition is not hampered by social determinants of health.

Consequently, with a straightforward level of MDM for the amount of complexity of data reviewed or analyzed, and a minimal risk of morbidity from any additional diagnostic testing or treatment, even with a low level of MDM for the patient’s condition, the overall level of MDM for this scenario only rises to straightforward at best. That means your MDM level only allows reporting 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making …) based on the information provided. Unless you have a notation of the time in the record that would support reporting 99213, then you are likely to be coding this service as 99212, depending on the rest of your documentation.