Coding the “Spot Check”: Part 1
The updated outpatient evaluation and management (E/M) coding paradigm went into effect in January 2021, with level of visit being based on time or medical decision making (MDM). This article discusses how to effectively utilize this coding structure to correctly document for the “spot check,” a common encounter within dermatology.
Practice Points
- Clear documentation that reflects your thought process is an important component of effective coding and billing.
- Include Current Procedural Terminology–defined language within documentation to help ensure appropriate reimbursement and decrease the risk of audits.
• Impression: rule out melanoma.
• Plan:
As was the case before 2021, you still need a CC, along with a medically (and medicolegally) appropriate history and physical examination. A diagnostic impression and treatment plan also should be included.
In this situation, reporting is straightforward. There is no separate E/M visit; only the CPT code 11102 for tangential biopsy is reported. An International Classification of Diseases, Tenth Revision code of D48.5 (neoplasm of uncertain behavior of skin) will be included.
Why no E/M code? This is because the biopsy includes preservice and postservice time and work that would be double reported with the E/M. Remember that the preservice work would include any history and physical examination related to the area to be biopsied.
Specifically, preservice work includes:
Inspect and palpate lesion to assess surface size, subcutaneous depth and extension, and whether fixed to underlying structures. Select the most representative and appropriate site to obtain specimen. Examine draining lymph node basins. Discuss need for skin biopsy and biopsy technique options. Describe the tangential biopsy procedure method and expected result and the potential for inconclusive pathology result. Review procedural risks, including bleeding, pain, edema, infection, delayed healing, scarring, and hyper- or hypopigmentation.5
