Questions on Established Patients, Medicare Services for Families, and Coding for Destructions

Our doctor did a biopsy on a suspicious lesion that turned out to be a hyperplastic AK with involved margins. Can we bill a malignant destruction code for this?

No. The malignant destruction codes are used for treatment of malignant lesions only. An AK is a premalignant lesion, meaning that it may develop into a malignancy, but if the pathologist called it an AK, for now it is benign. The options for coding this service are most likely:
• Extensive freezing, 17000;
• Shave removal, 113xx; or
• Excision of a benign lesion, 114xx.

We have a new doctor in our practice who worked in another practice in our city. Some of his patients have followed him to the new location. Since we have to enter them into our computer system and create new patient charts for them, shouldn't they be considered new patients?

CPT defines a new patient as one who has not received any face-to-face services from the physician or another physician of the same specialty in the same practice in the last three years. So, regardless of the circumstances under which the doctor saw the patient, if it was within the last three years, the patient is established. Take note, however, that you may actually be paid more for an established patient visit. Because only two of the three components (History, Physical Exam, Medical Decision Making) are required for an established patient compared to all three for a new patient, the same service will often support a higher established patient code, which may pay higher.

Here are some examples using a random area's fee schedule:
99201 –$39.72 99212 –$40.04
99202 –$68.73 99213 –$66.83
99203 –$99.25 99214 –$99.21

We saw a patient with warts, treated the warts (17110) and told him to return in six weeks. On the return visit the patient's mother was upset that we charged an E/M and destruction code (17110) on the same day. Is it not correct to charge for both?

Generally when the patient is told to return after an initial wart treatment, the medical decision has already been made to treat any remaining warts at that subsequent visit. The problem has already been evaluated, and the provider usually enters the room with the LN2 bottle in hand. Charging an E/M service under these circumstances would not be appropriate.

Our doctor did Mohs on his mother-in-law who had a skin cancer on her left cheek. Medicare denied the claim. Why?

Chapter 16, section 130 of Medicare's Benefit Policy Manual states that providers are not eligible for Medicare payment for care rendered to relatives. The list is rather extensive and does include mothers-in-law.