Just wondering if any coding gurus out there can answer this and if possible give some supporting references. The sections in brackets are what I am seeing in physician documentation (all PHI omitted).
Is it sufficient to list the number of lesions present in the PE [SKIN: 10 AKs present on the face, arms, and bilateral ears] to code 17000 x1 and 17003 x9 if the description of the procedure is vague in the A&P [Actinic Keratoses (L57.0) Cryotherapy (17000) (Routine)]?
Does the number of lesions removed need to be expressly specified in the documentation?
Any responses are appreciated.
Angela
Hi Angela,
I would query the provider if possible. You can't charge for something that is not documented. There could be a total of 10 AKs but that doesn't mean the provider removed all of them. If you have to code just based on the documentation you provided, you would downcode to 17000 because it is obvious that at least one AK was removed. To properly bill for 17003 in units, the number of AKs removed has to be stated, either in the PE or A&P, not the amount of AKs the patient has.
Wendy
Thank you for your response, Wendy. I was thinking the same thing. I had sent it back for clarification/adjustment of the CPT codes and/or documentation and got it back with no change in documentation and additional units of 17003 added. Just wondering if I was missing some thing there before I sent it back a 2nd time.
Angela
You're welcome. :0)