Minor skin procedures are performed by all types of physicians everyday in offices all across the country.  These include skin biopsies, lesion excisions, skin repairs, and lesion destructions.  Performing these procedures allows for valuable reimbursement for a primary care physicians office that otherwise may be billing mostly Evaluation and Management (E/M) codes.  This article will discuss documentation of these procedures and the use of templates to facilitate this documentation.

Issue #1: Documentation
One of the major problems with minor procedures performed in the office is that documentation is sometimes insufficient to support the services that were billed.  In most cases physicians have performed the service and bill for the service they performed, but the documentation does not support the service billed.  This leaves the physician in a bad position upon audit.

CPT codes and guidelines change every year and physicians must stay informed of the changes to their specialty.  This helps them to understand what documentation changes they need to make in their patient records when a procedure is performed.  For instance, the guidelines for lesion excision changed in 2003 to include the necessary margin in determining the size for coding purposes.  Physicians must be very specific in their documentation of excision size in order to support the code they choose.  Many physicians still do not document these services correctly. 

These services should be documented just as surgeries are documented.  There should be a reason for the procedure indicated, a pre-op diagnosis, a post-op diagnosis if something different is found, and a body of a report.  A lot of times the procedure is just stuck in the middle of an E/M note.  This would be very confusing to an auditor looking at the chart note.

Issue #2: Time
Physician patient visit numbers have become overloaded.  With the Medicare cuts and managed care contracted payments, some are seeing double the amount of patients to make the same amount of money they did 5 or 10 years ago.  When the patient loads become so overbearing something has to give for them to keep up.  Unfortunately, sometimes it's the documentation that suffers.

Some physicians do their charting at the end of the day, after seeing 40+ patients.  How concise is that chart note going to be for the first patient of the day at that point?  How specific (detailed) are the notes going to be on each patient?

Some doctors make the chart notations as they are seeing the patient, or right after, before going on to their next patient.  The problem here is, when there are many more patients waiting, the notations may be shortened in order to get to the next patient faster.  Or they are not informed of the proper documentation necessary for the procedure they preformed.

So, what is the answer?  How can we help the physicians document better without spending a lot more time documenting?  The answer is templates.  The use of templates is a great tool to ensure proper documentation without extra time being spent.  We will discuss templates for minor skin procedures, but this theory can be used for any minor procedures in the office.

Minor Skin Procedures
The types of procedures we are discussing are minor skin procedures.  These are the skin tag removals, lesion excisions, repairs, etc. that are performed by most physicians in their offices.  In the 10000 section of CPT numbers and accuracy is of great importance if you want to get paid correctly.  For example, skin tag removal groups the codes by number of tags removed, not by method of removal.  There are two codes possible for selection: 11200, Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions; or 11201, each additional 10 lesions.  If the physician documents removal of "about 15 lesions" what should be coded?  If it was 14 or 15 then it should be coded as 11200 only.  But if it was 16 or 17 then it should be coded as 11200 and 11201.  Using vague language may be losing revenue.