Criteria for 99213 Code Are Met for Most Visits : Documentation is the key: Dermatologists often fail to provide the necessary detail in their charts.

But billing for a 99203 also requires documentation of a more extended history of the present illness (four or more elements or three active or inactive problems) and an extended review of systems (two to nine systems, which may be captured in a form filled out by the patient and reviewed by the physician).

The 99203 code also requires documentation of "pertinent past personal, family, and social history" (such as illnesses, operations, treatments, smoking history, occupation).