Coding for the office visit in Skin Disease and Care (Table 10-1) - The office visit or evaluation/management (E/M) level is determined by documentation of three key components: history, physical exam, and medical decision making
- If counseling accounts for more than 50% of the face-to-face time during the visit, time is considered the controlling factor in determining the level of E/M service (not key components) and the total length of time needs to be documented
- For most visits, E/M level will depend on amount of documentation (not amount counseled)
- History:
- Chief complaint, review of systems (ROS), and personal/family/social history (PFSHx) can be listed as separate elements of the history or included in the description of HPI
- If a ROS or PFSHx was recorded at an earlier time, it does not need to be re-recorded if there is evidence that the physician reviewed and updated the information (initials/date)
- Elements (each of the following counts as one element): location, severity, timing, duration, quality, modifying symptoms, context, associated sign/symptoms
- Physical exam: need certain number of elements (each bullet in table below = one element)
- Decision making: need proper documentation (i.e., follow-up visit, it should be documented in the chart whether the problem is improving, stable, worsening, resolving, etc.)
| | | | | | | Table 10-1 Elements in Physical Exam | | (modified to reflect common circumstances in dermatological skin exam) | | | System/Body Area | | Elements in Physical Exam | | | Constitutional | | • General appearance of patient (e.g. well developed, well nourished)
• Vital signs, need three or more: BP/P/Temp/Ht/Wt | | | Eyes | | • Inspection of lids and conjunctivae | | | Ear/Nose/Throat | | • Inspection of lips, gum, and teeth
• Inspection of oropharynx
{Each bullet counts as one element}
| | | Neck | | • Examination of thyroid | | | Cardiovascular | | • Examination of peripheral pulses by inspection and palpation | | | Lymph nodes | | • Examination of lymph nodes in neck, axillae, and/or groin | | | Extremities | | • Inspection of digits and nails (clubbing, cyanosis, inflammation, etc.) | | | Skin | | • Palpation of scalp and inspection of hair of scalp, eyebrows, face, chest, extremities, and pubic area (when indicated)
• Head (including the face)
• Neck
• Chest (including breasts and axillae)
• Abdomen
• Genitalia, groin, buttocks
• Back
• Each extremity (i.e., RUE and LUE count as two elements)
• Inspection of eccrine and apocrine glands of skin and subcutaneous tissue | | | Neurologic/Psychiatric | | • Orientation to time, place, and person
• Mood and affect (e.g., depressed, anxious, agitated, pleasant) | | | | | |
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