Wiki Dermatology single system exam

[twizzle]

I have no dermatology experience and was taking a proficiency test for a part-time remote job.

One question about dermatology left me wondering. The patient was coming back 2 years post treatment for melanoma, basically for a screening exam.
Patient had a "lesion" on the nose.

Doctors exam says " head to toe dermatological exam reveals lesion on nose".

Surely there is not enough information there to give it a comprehensive level.

I gave it an EPF level because he documented something else as well...vitals I think.

Any thoughts on this?

 

[CatchTheWind]

First, it is practically impossible for a dermatologist to get a comprehensive level. The comprehensive exam (even for single organ system: skin) requires taking at least three vital signs, examination of such body parts as the liver, anus, and mouth, etc. And the Medical Decision Making (MDM) requires a very serious (generally life-threatening) condition. The only situation I can see in which you could get a comprehensive level in dermatology would be an established patient with (current) melanoma if you took a really, really good HPI, ROS, and PFSH.

Second, I do not believe that a statement "head-to-toe dermatological exam" qualifies as any exam at all without noting specifically which parts of the skin he examined. (Note that CMS's 1997 E/M Guidelines for a even a problem-focused single-system exam requires "performance and documentation of one to five elements identified by a bullet.")

That would leave your E/M level having to be based on your history and MDM. You did not mention was was documented in the history, so I can't comment on that. As for the MDM, if the lesion is documented as being new AND suspicious for skin cancer, you could get a moderate MDM; otherwise, you've only got a straightforward MDM.

 

[twizzle]

First, it is practically impossible for a dermatologist to get a comprehensive level. The comprehensive exam (even for single organ system: skin) requires taking at least three vital signs, examination of such body parts as the liver, anus, and mouth, etc. And the Medical Decision Making (MDM) requires a very serious (generally life-threatening) condition. The only situation I can see in which you could get a comprehensive level in dermatology would be an established patient with (current) melanoma if you took a really, really good HPI, ROS, and PFSH.

Second, I do not believe that a statement "head-to-toe dermatological exam" qualifies as any exam at all without noting specifically which parts of the skin he examined. (Note that CMS's 1997 E/M Guidelines for a even a problem-focused single-system exam requires "performance and documentation of one to five elements identified by a bullet.")

That would leave your E/M level having to be based on your history and MDM. You did not mention was was documented in the history, so I can't comment on that. As for the MDM, if the lesion is documented as being new AND suspicious for skin cancer, you could get a moderate MDM; otherwise, you've only got a straightforward MDM.

Thanks CatchTheWind.

I did get the right answer to that question by giving an EPF level for the exam.

Constitutional and "full head to toe skin exam" didn't justify anything higher because that statement doesn't provide much information. I just wasn't sure how dermatology coders would view it.

I appreciate your help