Wiki Found on exam

[AprilSueMadison]

Pt comes in for a mole that they believe is odd looking on their R arm. In the note, we have an HPI, a physical exam, and treatment summary for that lesion states cyrotherapy.

During the same visit, upon exam, the doctor finds a rash in between the patient's toes while looking for other moles. No HPI, found on exam, treatment summary is prescription given.

Do I have an office visit for the rash even though I don't have an HPI? I thought that was required.

 

[Pam Warren]

Are there elements of the history of the rash somewhere in the note? Not all history components are located at the beginning of the note. If within the Assessmen/plan or even in the exam, there are history elements noted, you can count them regardless of where they are documented in the body of the note. So if in the exam the provider relates, "rash between toes found on exam. Patient notes it has been there x 4 days, and is itchy and red", then you have a history. Also, the rash should be assessed, there should be a diagnosis (or verification of the rash as a symptom), and some treatment planning relative to the rash in order to support an additional visit.

 

[AprilSueMadison]

Here is an actual example I've just come across....

HPI -
L cheek
The problem is mild. The patient reports a prior history of skin cancer (basal cell carcinoma and squamous cell carcinoma). Associated symptoms include itchy skin and scaly skin.

Exam -
L face: erythematous hyperkeratotic plaque, 3-4mm in diameter
L wrist and L up arm: well defined hyperkeratotic, tan-brown stuck on plaques

Procedures -
Actinic keratosis 702.0 (L face (8) x 8)
Procedure: Destruction of actinic keratosis lesions with TCA 50%

Treatment Summary -
Actinic keratosis (L face (8)) Procedure today: Destruction of lesions with TCA 50%
702.0
Rough seborrheic keratosis (L wrist and L up arm) Treatment Plan: No treatment necessary today. Will observe.
702.19

Do I have an office visit for that?

 

[wrightju1]

No, you don't get to bill a seperate E/M for each Dx. Now, if he performed a procedure on the lesion and is billing for that you might support a seperate E/M with the 25 modifier for the rash. This is an established patient, so you don't need History. You just need Exam and MDM. Of course you would have different Dx on each code billed.