Wiki E/M based on exam

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jmessick

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A patient is seen and biopsy is done. Due to my understanding all HPI/exam/procedure for that lesion has to be taken out to code the E/M. Due to being a dermatologist and scanning for potential risk of other lesions a detailed exam is performed.
Would that detailed exam documenting normal lesions be a justifiable billable E/M?
 
Thanks, kbtritten, for that link to the NCCI. It's a good link to bookmark!

To answer the question, it is true that you have to "separate out" the parts of the HPI, exam, and MDM (medical decision making) that were related to the biopsy. But you can still code an E/M for the portions of the HPI, exam, and MDM that related to the exam of the other parts of the skin.

There's a good two-part article by Dr. Alex Miller on the AAD website about this. (Part 2 deals specifically with this issue, and Example 3 describes a scenario similar to yours. See http://www.aad.org/dw/monthly/2013/june/to-25-or-not-part-one#page1 and http://www.aad.org/dw/monthly/2013/july/to-25-or-not-part-two#page1)
 
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