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.
• Acute or chronic illness or injury that poses a threat to life or bodily function (level 5, or high-level problem)?1
• All of the above?
Similarly, there may be variation in how the risk (column 3) would be interpreted in this scenario. The treatment gives no guidance, so the auditor may assume this has a minimal risk of morbidity (level 2) or possibly a low risk of morbidity from additional diagnostic testing or treatment (level 3), as opposed to a moderate risk of morbidity (level 4).1The Takeaway—In the auditor’s mind, this could be a straightforward (CPT codes 99202/99212) or lowlevel (99203/99213) visit as opposed to a moderate-level (99204/99214) visit. From the above documentation, an auditor would not be able to tell what you are thinking, and you can be assured they will not look further into the diagnosis or treatment to learn. That is not their job. So, let us clarify by explicitly stating what you are thinking in the context of the MDM grid.
Modified Scenario 2: A Funny-Looking New Spot With MDM Descriptors to Guide an Auditor
Below are modifications to the documentation for scenario 2 to guide an auditor:
• 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
