At the Society of Dermatology Physician Assistants 19th Annual Fall Dermatology Conference  in Los Angeles, CA, Ahmad Amin, MD, shared what everyday dermatology providers need to know about the 2021 coding guidelines now that the updates have been out for approximately 1 year. Dr Amin is an assistant professor of dermatology and clinical practice director at Northwestern University Feinberg School of Medicine, where he also directs the psoriasis and psoriatic arthritis clinics.

The American Academy of Dermatology has a robust coding resource center, noted Dr Amin, who shared a worksheet from the center throughout the lecture.

Prior to the coding updates in 2021, the Current Procedural Terminology (CPT) coding for a new or established patient was based on factors from the history of present illness collection, the level of detail in the patient examination, and the medical decision making (MDM) and assessment plan. Now, the new changes seeks to simplify the coding into just the decision-making and assessment plan.

There are three factors to evaluate when determining the appropriate code for an appointment: number and complexity of problems addressed, amount and/or complexity of data to be reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management. Dr Amin shared that dermatologists often do not review/analyze data, so most of the factors will be related to the complexity/number and the complications of the problem. Essentially, for any level of service, there needs to be at least two elements of MDM that are either met or exceeded for that given level of service.

Complexity of problems are broken down as:

• Minimal problem (eg, nurse removes suture)
• Self-limited or minor problem (eg, benign moles, skin tags, itchy bug bite)
• Stable, chronic illness (eg, psoriasis on treatment)
• Acute, uncomplicated illness or injury (eg, abrasion, impetigo)
• Chronic illness with exacerbation, progression, or treatment side effects (eg, new active lesion of lupus erythematosus)
• Undiagnosed new problem with uncertain prognosis (eg, changing pigmented lesion)
• Acute illness with systemic symptoms (eg, drug-induced exfoliative erythroderma with shaking chills)
• Acute, complicated injury (eg, severe, extensive blistering/sunburns)
• Chronic illness with severe exacerbation, progression, or treatment side effects (eg, dermatomyositis with worsening muscle weakness)
• Acute or chronic illness/injury posing threat to life or function (eg, toxic epidermal necrolysis)

However, Dr Amin shared that some diseases or cases can fall into a few different complexity levels. He cited an example of a patient who presents with a dermatomal vesicular rash that is suspicious for herpes zoster and sampled for polymerase chain reaction. “Does that count as an acute illness or does that count as an undiagnosed new problem? So that’s where there is a little bit of a gray area,” he said.

Dr Amin then discussed several examples, including:

• Acne: patient has stable disease and is to continue treatment (benzoyl peroxide and clindamycin topical, tretinoin topical, and oral spironolactone); this patient would be billed as CPT code 99213
• Eczema: patient presents with a new disease flare and topical steroid potency is increased; this patient would be billed as CPT code 99214
• Psoriasis: patient has stable disease and continues to use clobetasol ointment, but the physician discussed the patient’s obesity and the importance of weight loss, proper diet, and exercise as part of the psoriasis care plan; this patient could be billed as CPT codes 99213 or 99214

Editor's note: this information is not intended to be advice for billing and coding.

Reference
Amin A. Billing & coding: maximize your collections. Presented at: Society of Dermatology Physician Assistants 19th Annual Fall Dermatology Conference; November 4-7, 2021; Los Angeles, CA.