In the case below can I bill it this way:
99202-25 dx 238.2
11100 dx 238.2
11101 dx 238.2
I'm getting a lot of conflicting information on these forums that you can or can't bill e/m with minor procedure even if it's a new patient.
Chief Complaint and/or History of Present Illness
Complaint(s):
1. Multiple growths and/or leisons on forehead, left cheek, left jaw and right cheek
Duration: few months
Severity: worsening
Quality: dull
Timing: constant
Past History
Past Medical History (PMH):
• Admits Hypertension
• Denies immunosuppressed, pacemaker, antibiotics prior to dentistry, skin cancer, hiv/aids, pregnant, nursing a baby,
hyperthyroidism, hypothyroidism, lupus, polycystic ovarian syndrome, blood clot, cancer, kidney disease, asthma,
hayfever, artificial joints or heart valves, diabetes, glaucoma and hepatitis
• Comments: Cholesterol
Family:
• Denies family history of acne, eczema, cancer, lupus, malignant melanoma, non melanoma skin cancer
and psoriasis
Review of Systems (ROS):
• Admits Integumentary System (skin problems)
• Denies bleeding problems, breathing difficulties, respiratory symptoms, cardiovascular problems or chest
symptoms, nausea,fever,diarrhea, endocrine related symptoms, eye or vision problems, gi symptoms,
joint or musculoskeletal symptoms, neurological symptoms or problems, psychiatric or emotional
difficulties, genital urinary symptoms, ear, nose, mouth or throat symptoms and integumentary
Social:
• Denies: Alcohol Use, Illicit Drug Use, Profession, Smoking (Never smoked), Tobacco / Smoking Cessation
Intervention, Tobacco Use
Surgical History
• Denies cancer surgery, gi surgery, heart surgery, joint replacement and plates/rods/screws/stents
Allergy:
• Patient denies allergy to medication
Medications
• HBP medication
• Cholesterol medication
Physical Exam, Diagnosis, Medical Decision Making and Plan of Care
Constitutional, Neurological and Psychiatric Notes:
• Patient is a 58 year old female who appears to be well developed and well nourished with good attention
to hygiene. Psychiatric Note: The patient appears to be oriented by time, place and person.
Skin Type:
• Patient has skin type IV (Beige with a Brown Tint).
Exam Type:
• Above the Waist Except Breast exam was performed on scalp (including hair), head (including face),
neck, axilla, right upper extremity, left upper extremity, hands, chest, abdomen, and back.
Exam:
1. Neoplasm of uncertain behavior, skin
Brown, hyperkeratotic, irritated, itching, papule (s), scaly located on forehead, left cheek, left jaw and right
cheek
Medical Decision Making: Neoplasm of uncertain behavior, skin , observe
POC: Recommendation is Bacitracin and dressing applied in office., Explained biopsy procedure to
patient. Discussed possibility of the need for further treatment based on pathology findings. Consent
obtained (see chart). Biopsy performed (see procedure note).
Biopsies:
1. Neoplasm of uncertain behavior, skin
Brown, Hyperkeratotic, Irritated, Itching, Papule (s) and Scaly located on Left Cheek, See Biopsy note for
details.
2. Neoplasm of uncertain behavior, skin
Brown, Hyperkeratotic, inflamed brown stuck on papules and plaques, Irritated, Itching, Papule (s) and
Scaly located on Left Jaw, See Biopsy note for details.
POC: Recommendation / comment: explained biopsy procedure to patient. discussed possibility of the
need for further treatment based on pathology findings. consent obtained (see chart). biopsy performed
(see procedure note)., bacitracin and dressing applied in office.
99202-25 dx 238.2
11100 dx 238.2
11101 dx 238.2
I'm getting a lot of conflicting information on these forums that you can or can't bill e/m with minor procedure even if it's a new patient.
Chief Complaint and/or History of Present Illness
Complaint(s):
1. Multiple growths and/or leisons on forehead, left cheek, left jaw and right cheek
Duration: few months
Severity: worsening
Quality: dull
Timing: constant
Past History
Past Medical History (PMH):
• Admits Hypertension
• Denies immunosuppressed, pacemaker, antibiotics prior to dentistry, skin cancer, hiv/aids, pregnant, nursing a baby,
hyperthyroidism, hypothyroidism, lupus, polycystic ovarian syndrome, blood clot, cancer, kidney disease, asthma,
hayfever, artificial joints or heart valves, diabetes, glaucoma and hepatitis
• Comments: Cholesterol
Family:
• Denies family history of acne, eczema, cancer, lupus, malignant melanoma, non melanoma skin cancer
and psoriasis
Review of Systems (ROS):
• Admits Integumentary System (skin problems)
• Denies bleeding problems, breathing difficulties, respiratory symptoms, cardiovascular problems or chest
symptoms, nausea,fever,diarrhea, endocrine related symptoms, eye or vision problems, gi symptoms,
joint or musculoskeletal symptoms, neurological symptoms or problems, psychiatric or emotional
difficulties, genital urinary symptoms, ear, nose, mouth or throat symptoms and integumentary
Social:
• Denies: Alcohol Use, Illicit Drug Use, Profession, Smoking (Never smoked), Tobacco / Smoking Cessation
Intervention, Tobacco Use
Surgical History
• Denies cancer surgery, gi surgery, heart surgery, joint replacement and plates/rods/screws/stents
Allergy:
• Patient denies allergy to medication
Medications
• HBP medication
• Cholesterol medication
Physical Exam, Diagnosis, Medical Decision Making and Plan of Care
Constitutional, Neurological and Psychiatric Notes:
• Patient is a 58 year old female who appears to be well developed and well nourished with good attention
to hygiene. Psychiatric Note: The patient appears to be oriented by time, place and person.
Skin Type:
• Patient has skin type IV (Beige with a Brown Tint).
Exam Type:
• Above the Waist Except Breast exam was performed on scalp (including hair), head (including face),
neck, axilla, right upper extremity, left upper extremity, hands, chest, abdomen, and back.
Exam:
1. Neoplasm of uncertain behavior, skin
Brown, hyperkeratotic, irritated, itching, papule (s), scaly located on forehead, left cheek, left jaw and right
cheek
Medical Decision Making: Neoplasm of uncertain behavior, skin , observe
POC: Recommendation is Bacitracin and dressing applied in office., Explained biopsy procedure to
patient. Discussed possibility of the need for further treatment based on pathology findings. Consent
obtained (see chart). Biopsy performed (see procedure note).
Biopsies:
1. Neoplasm of uncertain behavior, skin
Brown, Hyperkeratotic, Irritated, Itching, Papule (s) and Scaly located on Left Cheek, See Biopsy note for
details.
2. Neoplasm of uncertain behavior, skin
Brown, Hyperkeratotic, inflamed brown stuck on papules and plaques, Irritated, Itching, Papule (s) and
Scaly located on Left Jaw, See Biopsy note for details.
POC: Recommendation / comment: explained biopsy procedure to patient. discussed possibility of the
need for further treatment based on pathology findings. consent obtained (see chart). biopsy performed
(see procedure note)., bacitracin and dressing applied in office.