Wiki New patient dermatology skin check no hpi (help!)

[isleflow0r]

I cannot get an HPI for the life of me. Can family history of melanoma be counted as context for the below information gathered?

Chief Complaint: Mole Check

HPI: This is a 15 year old male who has a family history of melanoma, and is here for mole check. Pertinent negatives include: no previous history of skin cancer.

ROS and PFSH recorded. Patient had a detailed exam along with biopsies of 2 lesions examined on left arm and assessment of dysplastic nevus to right upper back with counseling and solar lentigines with counseling. I can get 2 of 3 from this visit but I know I need 3 of 3 for new patient.

Can family history be counted as context? Otherwise, can this be down coded to an established to meet at least the 2 of 3 for an established patient.

Any information will be appreciated. I have searched everywhere for answers.

 

[Mayzoo]

I am new at this, so a more experienced coder should also chime in.

You cannot convert a new patient to an established patient.

It appears to me you should code 99202, since his HPI contains one (CC) component.

 

[thomas7331]

I would agree that you can't change this to an established patient, and would also agree with counting the HPI as one element (since all we know is that it is a 'mole') - No matter how you try to count this, you could only justify a 'brief' HPI. Family history is part of PFSH not context for HPI.

I'd also mention though that since a minor procedure was performed at this visit (biopsy), the evaluation for that problem is considered part of the procedure and can't be separately coded. You would need enough separately identifiable E&M to support a modifier 25, and without additional HPI, I don't think you have that and can't support billing an E&M code.

 

[isleflow0r]

"procedure only" does not meet new patient requirements

Thank you. I was thinking this would be a "procedure only" as I didn't think I could get anything from HPI as family history would be considered part of PFSH. At most I was thinking context as that is how patient can have a malignant mole due to being a hereditary condition. I do not see this meeting new patient requirements and down coding this to procedure only.