When the Current Procedural Terminology (CPT) evaluation and management (E/M) reporting rules changed dramatically in January 2021, “bullet counting” became unnecessary and the coding level became 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
To make your documentation more likely to pass audits, explicitly link parts of your documentation to CPT MDM descriptors. Part 1 of this series discussed how to approach the “spot check,” a commonly encountered chief concern (CC) within dermatology, with 2 scenarios presented.2 The American Medical Association3 and American Academy of Dermatology4 have provided education that focuses on how to report a given vignette, but specific examples of documentation with commentary are uncommon. In part 2, we describe how to best code an encounter that includes a “spot check” with other concerns.
Scenario 3: By the Way, Doc
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.
- Impression: Rule out melanoma (undiagnosed new problem with uncertain prognosis).
- Plan: Discuss risks, benefits, and alternatives, including biopsy (decision regarding minor surgery with identified patient or procedure risk factors) vs a noninvasive gene expression profiling (GEP) melanoma rule-out test. (Based on the decision you and the patient make, you also would document which option was chosen, so a biopsy would include your standard documentation, and if the GEP is chosen, you would simply state that this was chosen and performed.)
As you turn to leave the room, the patient says:“By the way, Doc, can you do anything about these silvery spots on my elbows, knees, and buttocks?” You look at the areas of concern and diagnose the patient with psoriasis.
How would it be best to approach this scenario? It depends on which treatment option the patient chooses.
If you performed a noninvasive GEP melanoma rule-out test, the CPT reporting does not change with the addition of the new problem, and only the codes 99204 (new patient office or other outpatient visit) or 99214 (established patient office or other outpatient visit) would be reported. This would be because, with the original documentation, the number and complexity of problems would be an “undiagnosed new problem with uncertain prognosis,” which would be moderate complexity (column 1, level 4). There are no data that are reviewed or analyzed, which would be straightforward (column 2, level 2). For risk, the discussion of the biopsy as a diagnostic choice should include possible scarring, bleeding, pain, and infection, which would be best described as a decision regarding minor surgery with identified patient or procedure risk factors, given the identified patient concerns, making this of moderate complexity (column 3, level 4).1
Importantly, even if the procedure is not chosen as the final treatment plan, the discussion regarding the surgery, including the risks, benefits, and alternatives, can still count toward this category in the MDM table. Therefore, in this scenario, documentation would best fit with CPT code 99204 for a new patient or 99214 for an established patient. The addition of the psoriasis diagnosis would not change the level of service but also should include documentation of the psoriasis as medically necessary.