It is impossible to stress enough the importance of complete documentation of patients’ medical records.  This is not only an issue that directly impacts patient care, it is an issue that can have troubling financial consequences for a dermatology practice that does not follow the highest standards of documentation in the record and in the healthcare claims they submit to payers.

Proper and complete documentation does not end with entries in the patient’s record.  The record’s contents are the starting point in a chain of events that inform third party payers what services were performed and why they were performed.  The medical record, whether a paper chart or an EHR, whether it is written directly by a physician or dictated and transcribed, or if it is generated through voice recognition technology, is the foundation for every transaction that takes place after the patient has received care.

Professional medical documentationists, certified medical coders, and experienced medical billers know that if something is not documented, from a legal and coding standpoint, it didn’t happen.  By accurately translating entries in the patient’s record, these professionals assemble a medical claim using universally understood procedure and diagnosis codes.  

The language of medical code is very precise.  Codes are only assigned when they are supported by the available documentation.  For this reason the documentation needs to be complete.  When a dermatologist examines a patient, he or she needs to paint a clear picture of what they observe.  The location of the examination needs to be clearly documented, as do the findings.  The location of a lesion impacts not only diagnosis coding, but procedure coding, as well.  While there is a diagnosis code for a neoplasm of uncertain behavior of the skin (238.2), this diagnosis is meaningless when the lesion is completely removed in the office and submitted to pathology.  The excision is a definitive treatment, not a biopsy.

Excision of skin lesions are coded to reflect whether the lesion was benign or malignant.    An excision code cannot be paired with a code that states that the physician was uncertain of the lesion’s underlying pathology.  Submitting a CMS-1500 containing the codes 11401 (Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs, excised diameter 0.6 to 1.0 cm) with a diagnosis of 238.2 makes no logical sense.  This claim will be denied by a third-party payer, requiring re-coding and re-submission of the claim.

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A dermatologist who removes a benign lesion from a patient’s arm, needs to make the location clear in the patient’s record.  The statement, “keloid removed,” does not provide sufficient information for a coder to submit a meaningful healthcare claim.  

The location and the size of the keloid need to be documented in order to receive accurate reimbursement.  CPT code 11401 cannot be applied and billed unless the clinical information in the patient’s chart describes the lesion removed as being on the patient’s trunk, arms or legs.  The code set 11400 through 11406 all define the removal of benign skin lesions 11400 refers to lesions that are 0.5 cm or less in their greatest dimension, while 11406 refers to lesions that are over 4.0 cm in their greatest dimension.  Without knowing the dimensions, a coder cannot assign the appropriate code, and a biller cannot submit an accurate claim.  

The documentation standards required for accurate coding and reimbursement are not just a back office concern used by administrators to create additional paperwork for dermatologists.  The standards are what a healthcare provider would expect to find in a patient’s record if he or she was unfamiliar with the patient.  Good documentation is good medicine.  A patient’s past history and treatment guides future treatment.  This is why a dermatologist reviews the patient’s pertinent history at every examination.  

When the documentation is thorough, codes can be assigned accordingly, followed by the submission of clean healthcare claims that do not require appeals for reconsideration.  In the event of an audit by a payer, the healthcare claim will be compared to the available documentation to determine if a dermatologist has received proper payment for services provided, based on the coding.  If the documentation does not reflect what is described in the claim, the dermatologist will be liable for reduced payments, and potential punitive fines.

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