On January 1, 2021, the Current Procedural Terminology (CPT) evaluation and management (E/M) reporting rules changed dramatically, with “bullet counting” no longer necessary and the coding level now based on either the new medical decision making (MDM) table or time spent on all activities relating to the care of the patient on the day of the encounter.1 This is described in the CPT Professional Edition 2023, a book every practitioner should review annually.2 In particular, every provider should read and reread pages 1 to 14—and beyond if you provide services beyond standard office visits. These changes were made with the intent to simplify the process of documentation and allow a provider to spend more time with patients, though there is still a paucity of data related to whether the new system achieves these aims.
The general rule of reporting work with CPT codes can be simply stated—“Document what you did, do what you documented, and report that which is medically necessary” (David McCafferey, MD, personal communication)—and you should never have any difficulty with audits. Unfortunately, the new system does not let an auditor, who typically lacks a medical degree, audit effectively unless they have a clear understanding of diseases and their stages. Many medical societies, including the American Medical Association3 and American Academy of Dermatology,4 have provided education that focuses on how to report a given vignette, but specific examples of documentation with commentary are uncommon.
To make your documentation more likely to pass audits, explicitly link parts of your documentation to CPT MDM descriptors. We offer scenarios and tips. In part 1 of this series, we discuss how to approach the “spot check,” a commonly encountered chief concern (CC) within dermatology.
Scenario 1: A Funny-Looking New Spot
A 34-year-old presents with a new spot on the left cheek that seems to be growing and changing shape rapidly. You examine the patient and discuss treatment options. The documentation reads as follows:
• CC: New spot on left cheek that seems to be growing and changing shape rapidly.
• History: No family history of skin cancer; concerned about scarring, no blood thinner.
• Examination: Irregular tan to brown to black 8-mm macule. No lymphadenopathy.