Wiki Derm e&m

[dixiesheppick]

I have just started coding for Derm, my doc and I are in discussion concerning his E&M levels with regards to the exam portion. I know for 1995 guidelines it would be 4 areas checked.

Someone please help me with the 1997 skin exam, because there is a note under the "Skin box" that states " For the comprehensive level, the examination of all 4 anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately". So what level of exam would you get for the following note for 1997 guidelines? I would appreciate any help at all!

General Examination:
GENERAL APPEARANCE: healthy appearing, pleasant, NAD.
NEUROLOGIC: alert and oriented.
PSYCH: mood/affect appropriate.
Dermatology:
SCALP: AK's.
FACE: within normal limits.
EYELIDS: within normal limits.
LIPS: within normal limits.
NECK: within normal limits.
CHEST: within normal limits.
ABDOMEN: within normal limits.
BACK: dark macule 5 cm L of T12.
R UPPER EXTREMITY within normal limits.
R HAND/FINGERS within normal limits.
L UPPER EXTREMITY L proximal third forearm keratotic papule, AK's .
L HAND/FINGERS within normal limits.
L LOWER EXTREMITY within normal limits.
R LOWER EXTREMITY within normal limits.

 

[CatchTheWind]

In dermatology, you are not likely to EVER get a comprehensive, because it involves examination of organ systems that don't concern dermatology.

The points you can get for a derm exam in the 1997 guidelines - one point for each item on the list - are:

SKIN OF:
scalp
head and/or face
conjunctivae and/or eyelids
lips, gums, and/or teeth
neck
chest
abdomen
genitalia, groin, and/or buttocks
back
R upper extremity
L upper extremity
R lower extremity
L lower extremity

OTHER:
digits and/or nails
sweat glands
oropharynx
thyroid
vascular system
liver and spleen
anus
lymph nodes
appearance
orientation
mood

If you can check 12 items on that list*, you get a detailed exam. 6-11 gets an expanded problem-focused exam. 1-5 is problem-focused.

*This is assuming two things: That it was medically necessary to examine each of these areas (given the patient's complaint), and that you have subtracted from the list any areas that were examined as part of an office procedure the same day.

 

[dixiesheppick]

Thanks again!