Category: CC-Dermatology

Seborrheic Keratosis
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Seborrheic Keratosis

February 15, 2024 Question: What diagnosis code would I use to report a seborrheic keratosis? Answer: Seborrheic Keratoses are benign lesions. The typical diagnosis is L82.1 (other seborrheic keratosis) but if inflamed the correct diagnosis is L82.0 (inflamed seborrheic keratosis). *This response is based on the best information available as of 2/15/24.    

Coding Question on a Diagnosis
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Coding Question on a Diagnosis

February 1, 2024 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...

Procedure Coding
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Procedure Coding

December 28, 2023 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...

Time Reporting for E/M Levels
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Time Reporting for E/M Levels

December 14, 2023 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...

Time
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Time

November 30, 2023 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...

Date of Service
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Date of Service

November 16, 2023 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...

Diagnosis Coding Excludes 1 Codes
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Diagnosis Coding Excludes 1 Codes

November 2, 2023 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...

E&M Coding Based on Time
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E&M Coding Based on Time

October 19, 2023 Question: Our physicians’ defaults to time for almost every office encounter. We are working with them on documentation and what work contributes to total time and what does not. They perform their own procedures such as skin lesion removal and biopsies in the office. They are counting the total time spent with...

Modifier Order on CMS Claim Form
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Modifier Order on CMS Claim Form

October 5, 2023 Question: We are submitting a hospital claim form with the modifier 25 and FS modifier. We are unsure which modifier to list first. What is your recommendation? Answer: Thanks for contacting KZA and remembering to use the FS modifier for shared services provided in the hospital. KZA recommends placing the modifier 25...

Coding for a Laceration Repair
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Coding for a Laceration Repair

August 3, 2023 Question: I repaired a 12 cm jagged laceration of the midabdomen by undermining 1cm to release the skin edges. Due to the length of the laceration and potential wound tension concerns, I closed the laceration in layers and retention sutures are used. What procedure code should I report? Answer: Good question. Because...

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