Patient’s chief complaint is ‘presents for removal of lesion’
HPI: lesion present for 3 months and growing
ROS
EXAM
Lesion removed
impression;
BCC
not sent to pathology
not confirmed as BCC
Since the patient presented for the sole reason of having the lesion removed, and the procedure was reasonably anticipated, I do not think this E/M situation is warranted.
Furthermore, I don’t believe this can be accurately coded without a pathology report.
I would code this to a lesion of the skin: L98.9 until pathology confirms.
Please advise on the issues I have raised here, primarily ordering an E/M with a minor procedure when the procedure is planned or reasonably anticipated.
Thanks.

establish outpatient visit.

I have a question in regards to CPT code 99214 in order to qualify for this level 4 elements of the HPI or 3 Chronic conditions plus one pertinent PFSH.

so in order for me to select this code i have to have 1 of the PFSH?? What if I have a detail HPI & ROS with no PFSH is this still considered 99213?