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.
Postservice work includes:
Instruct patient and family on postoperative wound care and dressing changes, as well as problems such as bleeding or pain and restrictions on activities, and follow-up care. Provide prescriptions for pain and antibiotics as necessary. Advise patient and family when results will be available and how they will be communicated. The pathology request form is filled out and signed by the physician. Complete medical record and communicate procedure/results to referring physician as appropriate.5
The Takeaway—Procedure codes include preservice and postservice work. If additional work for the procedure is not documented beyond that, an E/M cannot be included in the encounter.
Scenario 2: What If We Don’t Biopsy?
• 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.
