Wiki Need help with this E/M please

[AprilSueMadison]

My question is, does the personal history of skin cancer give me an EM code by itself? And if so, what code do you get from this? Thank you for your help!

This is an existing patient....

History of Present Illness:
1. Lesion - The patient presents with lesion(s) that began gradually. Area(s) of concern include the R tip of nose. Associated symptoms include erythema, scaly skin and skin irritation.
2. History of skin cancer - The surgical site is healed. Patient has a history of skin cancer located on the R sidewall nose 2013 SCC. Associated symptoms include erythema. Wants it checked

Extended ROS was completed.
Pertinent PFSH was completed.

Physical Exam
Derm Exam
The following areas were examined by inspection and/or palpation and found to be normal except as noted in the significant findings below: head / face, neck, chest, abdomen, back, left upper extremity, right upper extremity, left lower extremity, right lower extremity and scalp / hair.
Psychiatric
Orientation - Oriented to time, place, person & situation.

Exam Findings:
R tip of nose: 4mm crusted plaque
L malar: erythematous hyperkeratotic plaque, 3-4mm in diameter
R sidewall nose and 2013 SCC: well healed surgical site, no sign of recurrence

Procedures:
Site # 1: Neoplasm of uncertain behavior 238.2 (R tip of nose x 1) - biopsy
Site # 2: Actinic keratosis 702.0 (L malar x 1) - destruction

Assessment
Neoplasm of uncertain behavior 238.2
Actinic keratosis 702.0
Personal history of skin cancer V10.83

 

[AprilSueMadison]

Anyone?

 

[dyorkovich]

I believe a low level E/M would be appropriate in this case, along with the procedures performed. Patients with a history of skin cancer commonly present for a full exam of the skin for monitoring and to see if new lesions have developed. That type of exam on its own would be a billable service. Also, I don't believe that examining all of the body areas listed in the exam would be integral to the biopsy of the nose.