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hkatie

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I've been running into some new documentation patterns at my practice lately and could use some feedback. This is an example of a CC and HPI I've started seeing:

CC: Full body skin examination

HPI: xx year old female/male is here for a full body skin examination. Pertinent negatives include: no family history of melanoma, no previous history of skin cancer, and no family history of non-melanoma skin cancer. She is being monitored for the development of new lesions.

I'm not seeing anything compelling for medical necessity in this scenario. Am I off target? Thanks in advance for feedback.
 
Thanks for your response, Debra. Just to be clear, would you list the preventive skin screening code first and then follow it with the findings (nevi, ak, etc.)? Thanks, Katie
 
If there were any positive findings, I would list those first, as they are the ones that are medical necessity, and thus (hopefully) payable.

However, if this is a new patient, your provider didn't capture enough information in the HPI to get an E/M visit anyway. But as long as this is an established patient (and as long as the positive findings didn't result in same-day procedures), you can get points from your exam and MDM from which to bill an office visit.

You touched on the problem all dermatologists have with billing for skin screening. There have been some recent threads on the subject. See https://www.aapc.com/memberarea/forums/showthread.php?t=74176&highlight=screening and https://www.aapc.com/memberarea/forums/showthread.php?t=110772&highlight=screening
 
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