KOLOA, HAWAII The "vast majority" of dermatologic office visits ought to be coded as level 3 services using the CPT evaluation and management codes, Dr. Allan Wirtzer said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.
"Based upon the work performed by most dermatologists, CPT codes 99203 and 99213 should be the default codes used for the typical dermatologic encounter. I know that may not be what you've heard … but I think from a documentation standpoint you can support this in the vast number of patients that you see in your office," said Dr. Wirtzer, a dermatologist and coding expert in private practice in Sherman Oaks, Calif.
It's all a matter of documentation, he said, and dermatologists seem to finally be getting the message. Historically, their use of level 2 coding greatly exceeded that of level 3, but the most recent Medicare utilization data indicate they're currently coding 90% of encounters as level 2 or 3, with the two levels seeing equal use. That's a big improvement, but it indicates there is still significant undercoding by dermatologists, since level 3 coding should predominate, he said.
To qualify as a code 99213 for established patients, any two of the following three key elements must be met: an expanded problem-focused history, an expanded problem-focused physical examination, and a low level of medical decision making. The requirements needed to fulfill these elements are detailed in the 1995 and 1997 documentation guidelines for evaluation and management services and can be accessed at www.cms.hhs.gov/MLNEdWebGuide
The most important of these key elements to document is the history, since it contains the details needed to meet both the history and decision-making components of a 99213. A patient with one worsening or two stable problems meets the requirement for low-level decision making, while one new problem qualifies for moderate-level decision making. The great majority of existing patients who visit a dermatologist fall into one of these categories, Dr. Wirtzer said.
An expanded problem-focused history has two components: a brief history of the present illnessa simple comment such as "acne on face" or "bump on leg" meets this standardand a problem-pertinent review of systems.
"If you can just put down that the patient is otherwise well or has no other complaints, you've done a problem-pertinent review of systems," he stressed.
The price for not properly documenting a claimed level of service can be steep. "If a physician gets audited and the insurance companies look at 15 of the 99213s that have been filed, they'll say, 'Listen, based on the fact that half of the charts we audited were wrong, we're going to assume that half of all your 99213s were wrong, therefore for the last year you owe us X amount of dollars,'" Dr. Wirtzer cautioned.
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To qualify as a code 99213 for established patients, two of three key elements must be met. DR. WIRTZER