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

SAN DIEGO — The "vast majority" of dermatologic office visits qualify for a CPT code of 99213, so long as they are properly documented, Dr. Allan S. Wirtzer said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"Most dermatologists tend to undercode for their services," asserted Dr. Wirtzer, a dermatologist in private practice in Sherman Oaks, Calif., who also chairs the American Academy of Dermatology task force on coding and reimbursement.

Quite simply, he said, a 99213 requires two of three major criteria, which can be fulfilled by properly examining and treating an established patient whose acne is flaring, for example.

To illustrate the point, Dr. Wirtzer detailed how a hypothetical patient visit would meet all three required elements for a hypothetical patient visit—more than are required for a 99213.

1. Expanded, problem-focused history, including a brief history of present illness (one to three elements that can include body site, duration, quality, severity, timing, context, modifying factors, or associated signs and symptoms): Acne check, flaring for 2 months. Problem-pertinent review of systems (integumentary system, constitutional system): No other skin complaints; patient reports good general overall health.

2. Expanded, problem-focused physical examination, including limited exam of the affected body area or organ system and other symptomatic or related organ systems (requires 6–11 areas): Multiple papulocystic lesions on cheeks. Chest, back, and neck are clear. Patient appears generally well, is alert, well oriented, and pleasant.

3. Low level of decision making (two stable problems or one worsening problem or new problem): Worsening problem (flaring for 2 months).

Dermatologists generally perform the necessary tasks required for a 99213 in visits with established patients, but they fail to provide the necessary detail in their charts when describing what they've done, Dr. Wirtzer said.

Many elements of the history can be completed using patient intake forms filled out in the waiting room, reviewed by the physician, and placed in the chart. Without this simple step, a visit that would have easily qualified for a 99213 can be billed only as a 99212, he said.

For established patients, history taking and documentation assume a special importance since they can fulfill two of the three elements that are required for a 99213 visit.

Make sure patients are asked about the number and types of problems they have on each visit, and any other related symptoms they may be suffering, Dr. Wirtzer suggested.

For example, an acne patient's upset stomach may be caused by the antibiotics that were prescribed for his or her skin condition. This finding is important to document, and contributes both to the problem-pertinent review of systems in criterion 1 and to criterion 3 since it speaks to the level of decision making. This "new problem" requires consideration of various alternative dosing strategies or therapies.

An expanded, problem-focused physical examination documenting 6–11 elements constitutes one of two elements justifying a billing level of 99213. A detailed physical examination that contributes to a billing code of 99214 requires more than 12 elements. (See box.)

The thresholds may sound hard to fulfill in a dermatologic examination, but they actually aren't, Dr. Wirtzer said at the meeting.

Each body site counts as one element, so a thorough skin examination of the head, neck, chest, back, abdomen, and each extremity totals nine elements, he pointed out.

Often overlooked are constitutional and neurologic/psychological systems, including the general appearance of the patient (one element) and orientation as to time, place, and person (one element).

Although most patient visits do justify a 99213 billing code, Dr. Wirtzer cautioned against overusing the code for very brief, routine follow-up visits in which detailed histories and examinations would be superfluous.

Billing every routine acne visit as a 99213 "sticks out on a computer as an aberration," he said.

If auditors see overreaching for codes, they may assess a penalty on a large proportion of all 99213 visits a physician has billed.

Furthermore, using a 99203 code for a new patient visit is not automatic. As with a 99213, billing for a 99203 requires very specific and proper documentation, he said.

A full-body examination, which Dr. Wirtzer believes should be conducted on every new patient, easily fulfills the requirements for a detailed physical examination, but the patient's chart must include at least 12 of the bullet items that are included in the skin examination. (See box.)

Furthermore, the "low level of decision making" required for a 99213 is automatically fulfilled in any new patient, since any problem that he or she describes is new, he said.