Proper, adequate coding and documentation has become an increasingly important aspect of modern medicine, especially with the prevalence of electronic health records (EHR). While electronic records provide some documentation benefits to the physician, such as legibility and ease of inter-physician communication, they also carry potential coding risks.
Many EHR systems automatically calculate the level of service and procedure codes based on physician documentation. This can be convenient but carries the risk of coding incorrectly and potentially reduces the incentive to learn the nuances of coding. Regardless of the coding generated by the EHR or billing staff, the physician is ultimately responsible.
Dermatology is one of the more complex specialties when it comes to coding and billing. Coders must be familiar with benign and malignant masses along with actions such as shaving, destruction, and performing biopsies. In addition, they must identify simple, intermediate, and complex repairs, and deal with sizing terms such as length, depth, width, and circumference. And don’t forget knowing the difference between centimeters and millimeters.
Dermatologists are very adept at providing their coders with the information they need to code correctly, but this may not be the case for all other providers. Coders who need to code dermatology-related procedures need to understand what each skin condition really is.
Dermatology New CPT Code Updates
- Reflectance Confocal Microscopy has new codes from CPT 96931-96936: RCM Codes 96931 i.e. image acquisition, interpretation and report, first lesion, 96932 image acquisition only, first lesion, and 96933 i.e. interpretation and report only, first lesion, +96934 i.e. image acquisition, interpretation and report, each additional lesion, +96935 i.e. image acquisition only, each additional lesion, and +96936 (interpretation and report only, each additional lesion).
- These codes apply to a free-standing device that produces stacked mosaic images but not for a hand-held confocal device.
- New Category III CPT Codes designated for emerging technology, services and procedures are temporary numerical codes ending with a T.
- Use CPT 0394T for high dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry when performed. Code 0182T for brachytherapy code has been removed.
Procedures with the MelaFind device can be reported using CPT 0400; multi-spectral digital skin lesion analysis for detection of melanomas and high-risk melanocytic atypia, one to five lesions. Use CPT 0401T for six or more lesions
Each year brings a few changes in CPT codes. There may be new codes, codes revised through addition or deletion of text, or codes for which portions of the text are rewritten.
By this point in the year, practices hopefully are aware of 2009 CPT Code changes relevant to dermatology, though there may be some confusion about what specifically was changed. Some practices may not be aware of changes to codes they use less frequently. To be sure your practice is current, here’s a look at several revised codes that are of interest to dermatology.
Correctly applying modifiers in the dermatology CPT Codes it requires a deep understanding of all the components and documentation requirements in codes with global periods. Only then can you choose the correct modifiers where applicable and avoid triggering an audit.
When you have implemented a professional medical billing and coding system which reflects these updates as the dermatology CPT codes are automatically generated. Hence; when your practice has access to the most up-to-date coding guidelines and information about regulations, you may have the potential to obtain maximum reimbursements. Such automatic coding can help increase efficiencies and productivity in your practice.