Primary Care Coding Alert

Question: A 13-year-old established patient reports to the FP for treatment of his acne. During an expanded problem focused history, the practice's non-physician practitioner (NPP) learns that the patient tried several over-the-counter acne treatments, but nothing worked. The NPP diagnoses camedopapular acne, prescribes a medication regimen and sends the patient home (medical decision making [MDM] was straightforward). What would be the nature of presenting problem (NOPP) and E/M code for this encounter?

California Subscriber

Answer: The NOPP in this encounter is most likely self-limited or minor or of low severity, though you might want to double-check with the NPP to be sure. Based on the extent of the history and MDM noted, you should report the following:

• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components; a problem focused history; a problem focused examination; straightforward medical decision making ...) for the E/M
• 706.1 (Diseases of sebaceous glands; other acne) appended to 99212 to represent the patient's acne.

Explanation: The E/M codes recognize five types of NOPP: minimal, self-limited or minor, low severity, moderate severity, and high severity. Per CPT, a self-limited or minor problem is one that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status; alternatively, it may be a problem that has a good prognosis with management/compliance.

For a low severity NOPP, the patient's condition must fit the following criteria:

• Risk of complete sickness (i.e., morbidity) without treatment is low;
• There is negligible (or no) risk of dying without treatment;
• The patient is expected to make a full recovery without incurring any other medical issues/side effects, such as functional impairment.