Wiki Significant? E/M

[hkatie]

I'm soliciting opinions on the following note. Would you bill for an office visit? Thanks in advance for your help.

"Patient complains of enlarging papule on left cheek with occasional pain and no bleeding.

8 x 10 mm crusted papule of left cheek

A/P Likely SCC
1% xylo, biopsy by shave technique, AlCl, well tolerated without complications.

Mohs if positive"

Thanks again and Happy New Year,

Katie

 

[mitchellde]

I do not see a significant office visit documented. I would bill the procedure only..

 

[MnTwins29]

Agree w/ Debra

The portion that could be considered E/M services appear to be the pre-procedure exam, even though it is a minor procedure. Not enough to warrant separate E/M, IMO