Wiki 99215 based on time?

[JesseL]

Is the documentation I have below sufficient for 99215?

If not, please let me know what else is needed in the documentation.

Basal cell carcinoma of other specified sites of skin
1cm erythema nodule located on left side of vulva
Medical Decision Making: Basal cell carcinoma of other specified sites of skin , problem worse
POC: Mupirocin 2% nasal ointment [mupirocin 2% nasal ointment]
Recommendation is , 5fu 0.5cc diluted with bacteriostatic water 0.5cc = total of 1cc injected into bcc site.
see procedure note. spoke with patient's daughter-in-law over the phone
explaining skin condition, which is regrowth of basal cell carcinoma. suggested either 2 options: 1. Wide
excision or Mohs surgery by Dr. Hillary Johnson (information about Dr. Johnson given to patient); 2. Trial
of erivedge, chemotherapy drug used for inoperable skin cancer, since patient is 96 years-old. Paperwork
faxed to Genentech. Meanwhile, patient should return to clinic next week to recheck area and serial
injections of 5-FU to keep tumor small. [extended visit: 40 min face to face consult]

 

[dmaguire]

You need more than (40 min spent face to face in counceling). You will want to them to state that 30 min of the total 40 minute visit was spend in counceling and cordination of care, Or more than 50% of the visit was spent in counceling and cordination of care. I hope this help you.

Danielle

 

[JesseL]

You need more than (40 min spent face to face in counceling). You will want to them to state that 30 min of the total 40 minute visit was spend in counceling and cordination of care, Or more than 50% of the visit was spent in counceling and cordination of care. I hope this help you.

Danielle

Yea I was hoping saying 40 min spent face to face on counseling was enough.

So because the dr didnt specify how much time spent on cordination of care i cant code 99215?

 

[mlbaker1974]

To make the statement acceptable in the future the provider should add total visit time, ie 50 minute visit with 45 minutes spent face-to-face with patient discussing/counseling regarding xxx.