bwerner
Networker
Hello,
We just got a dermatologist at our clinic and I have a question on E/M Levels. He does pretty well in the HPI and PLAN. I'm confused on how the exam needs to be documented and how to add up the points to get a higher level than a 99201. These are all new patient's to him since we have never had a dermatologist before.
Here is his exam.
" I looked at him from head to toe, exmaining all body surgaces and I think you can add all of the body parts there, but I see no indiciation of any melanoma or skin cancer. He has mild sun damage on his face and he has a number of moles on his back, but they are all within normal limits."
No vitals, I see one body system and I'm not sure what to do with this.
Any suggestions would be great. If he were to document all the body parts checked, can you count each body part?
Thanks in advance
Becky
We just got a dermatologist at our clinic and I have a question on E/M Levels. He does pretty well in the HPI and PLAN. I'm confused on how the exam needs to be documented and how to add up the points to get a higher level than a 99201. These are all new patient's to him since we have never had a dermatologist before.
Here is his exam.
" I looked at him from head to toe, exmaining all body surgaces and I think you can add all of the body parts there, but I see no indiciation of any melanoma or skin cancer. He has mild sun damage on his face and he has a number of moles on his back, but they are all within normal limits."
No vitals, I see one body system and I'm not sure what to do with this.
Any suggestions would be great. If he were to document all the body parts checked, can you count each body part?
Thanks in advance
Becky