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Coding Question on a Diagnosis
Question:
What is Actinic Keratosis and what procedure is used to treat this condition?
Answer:
Actinic Keratoses is an extremely common dermatological condition among the elderly. It is suspected to be a pre-malignant condition. The condition presents as rough, sometimes red, scaly patches on the skin, typically where there has been exposure from the sun. Common areas are the face, scalp, neck, ears, forearms, and hands. While they are mostly benign lesions, most squamous cell carcinomas begin as actinic keratoses, making it preferable to remove or destroy them before it can progress into malignancy. Treatment for Actinic Keratoses is cryotherapy which is a destruction.
The procedure to destroy or remove actinic keratoses are generally covered by Medicare and commercial payers. The CPT code to report actinic keratosis destruction is 17000 for the first lesion, 17003 for the second through 14th lesions (each lesion) and 17004 for 15 lesions or more and is reported only once. The diagnosis code for Actinic Keratosis is L57.0.
*This response is based on the best information available as of 2/1/24.
Procedure Coding
What is the difference between a biopsy and removal when it comes to dermatology.
Question:
What is the difference between a biopsy and removal when it comes to dermatology.
Answer:
A biopsy is a sample of a suspicious lesion on the body and the tissue is sent to a laboratory for testing. Where shave excisions are removals of lesions without taking the full thickness of the skin. These codes include local anesthesia. The wounds do not require suture closure.
*This response is based on the best information available as of 12/28/23.
Time Reporting for E/M Levels
My physician is billing office visits 99202-99215 based on time only. Is this best practice?
Question:
My physician is billing office visits 99202-99215 based on time only. Is this best practice?
Answer:
The E/M services 99202-99205 are based on either medical decision making or time.. Practitioners may choose to either bill by time or medical decision making. The practitioner should evaluate each patient encounter to determine which method is more advantageous. If time is used to calculate the E/M service, the total time should include all work associated with the patient encounter on the date of service. KZA recommends that the practitioner document an attestation statement itemizing the time spent on the specific activities for the patient. Example:. “This encounter took 45 minutes of time including taking a history, performing the examination, reviewing the CT scan, reviewing the PCP’s notes, counseling the patient on the conditions treated formulating a plan of care as well as documenting in the EHR.”
*This response is based on the best information available as of 12/14/23.
Time
Our physician is coding by time; he thinks this is the best for him. Frequently with a new patient he will also do an injection. He documents his total time for the day but does not document the amount of time performing a minor procedure (billable). There is no documentation of the time spent preparing for or performing the minor procedure. May we still report a service based on time?
Question:
Our physician is coding by time; he thinks this is the best for him. Frequently with a new patient he will also do an injection. He documents his total time for the day but does not document the amount of time performing a minor procedure (billable). There is no documentation of the time spent preparing for or performing the minor procedure. May we still report a service based on time?
Answer:
CPT states “Time” may be selected based on the total amount of time spent on the date of encounter, excluding time spent for services that are defined by a separately reportable CPT code. This means that the total time must exclude the amount of time spent related to the minor procedure. If not documented, KZA recommends asking the physician to amend the note if possible (attesting that the time is accurate to the best of their knowledge) or reporting the service based on MDM.
*This response is based on the best information available as of 11/30/23.
Date of Service
We are in an academic setting. Our residents will see a patient, for example, at 11 pm on Tuesday. Wednesday morning, our attending physician evaluates the patient, documents his/her findings, documents the required attestation, and enters an E&M into the EHR. The date of service is the date the encounter was created by the resident on Tuesday. Do you bill the E&M with the Tuesday date of service or the Wednesday date when the attending physician saw the patient?
Question:
We are in an academic setting. Our residents will see a patient, for example, at 11 pm on Tuesday. Wednesday morning, our attending physician evaluates the patient, documents his/her findings, documents the required attestation, and enters an E&M into the EHR. The date of service is the date the encounter was created by the resident on Tuesday. Do you bill the E&M with the Tuesday date of service or the Wednesday date when the attending physician saw the patient?
Answer:
The correct date of service is the actual date of service when the attending physician saw the patient. In this case, it will be Wednesday even if the attending physician links the note to the resident note from the previous date.
*This response is based on the best information available as of 11/16/23.
Diagnosis Coding Excludes 1 Codes
Our physicians list their diagnosis codes in the Assessment section of their notes. They link the diagnosis codes to the charges in our EHR. We receive a claims submission edit stating the two diagnosis codes may not be reported together. We review the rules and find the codes have an “Excludes 1” relationship. Our question is, should we remove the diagnosis code that is listed as the “Excludes 1” from the Assessment section of the note when correcting the claim based on the guidelines.
Question:
Our physicians list their diagnosis codes in the Assessment section of their notes. They link the diagnosis codes to the charges in our EHR. We receive a claims submission edit stating the two diagnosis codes may not be reported together. We review the rules and find the codes have an “Excludes 1” relationship. Our question is, should we remove the diagnosis code that is listed as the “Excludes 1” from the Assessment section of the note when correcting the claim based on the guidelines.
Answer:
No don’t do that but it is great news to hear you are reviewing your claims edit reports in a timely manner. The “Excludes 1” is an ICD-10-CM coding guideline or a coding rule. Think of this like an NCCI edit; when CMS has an edit between 2 CPT codes, we do not change the documentation in the operative note. Rather, we report the most comprehensive of the 2 CPT codes. The “Excludes 1” guideline is a similar concept—we do not change the documentation; rather, we report the most comprehensive diagnosis code.
*This response is based on the best information available as of 11/2/23.