Preventative Skin Check Coding

Question:

Can you clarify visit elements and review of systems are required for a preventative skin check? I have been told a full ROS is required for a preventative skin exam, as well as, medical and family history, lifestyle counseling, and age/gender appropriate screening performed. I believe dermatology to be problem oriented and a skin cancer screening vs preventative has been a huge gray area for me. Can you clarify the difference and requirements to be truly a dermatology preventative visit?

Answer:

The confusion arises because full-body skin cancer screenings in dermatology are rarely actual preventive medicine visits. Dermatology is specialty care, not primary care. Preventive medicine codes are typically reserved for primary care physicians providing comprehensive preventive services not performed in Dermatology, as they would be conducted in primary care. If you're performing a skin exam, you're not meeting the requirements for a preventive medicine visit (which requires multi-system examination and comprehensive counseling beyond just skin).

A dermatology skin cancer screening is appropriately coded as a problem-oriented visit with documentation matching the medical necessity and level of service provided based on either medical decision making or time.

For a routine skin cancer screening in dermatology, you should:

• Code as a problem-oriented visit (most commonly 99203/99213)

• Document risk factors justifying the exam

• Perform a clinically appropriate history and exam

• Document the assessment and plan of care relative to the history and examination

You will only bill a preventive medicine code if you provide comprehensive age-appropriate preventive services as a primary care provider would, which is not the typical dermatology scenario

*This response is based on the best information available as of 10/23/25.

Pyogenic Granuloma

Question:

Hello! Could KZA clarify if the excision of a pyogenic granuloma (lobular capillary hemangioma) would be assigned to a code from the musculoskeletal or integumentary system? We have seen some conflicting information.  

Answer:

Thank you for reaching out to KZA!

The origin of the lesion will direct you to the appropriate code selection.

According to CPT:

• Lesions of cutaneous origin are appropriately reported with the excision of lesion integumentary codes (114xx & 116xx).

• Lesions of non-cutaneous origin are appropriately reported with the excision of tumor codes from the musculoskeletal section of CPT (2xxxx).

Pyogenic granulomas are benign, generally considered of cutaneous origin, and reported with a 114xx benign lesion code. If the documentation is unclear, it is best practice to query the surgeon for clarification.

*This response is based on the best information available as of 10/09/25.

Reporting Modifiers with Unlisted Codes

Question:

Can modifiers be reported with unlisted CPT codes?

Answer:

Yes, modifiers can be appended to unlisted CPT codes.

In 2024, CPT clarified this by updating the introduction guidelines for unlisted procedures and services. These updates were further explained in the January 2024 issue of CPT Assistant, which addressed the new and revised text and the standardization of reporting unlisted CPT codes across the CPT code set.

Illustration of modifiers that may be appropriately applied includes:

• Laterality modifiers – e.g., RT (right), LT (left)

• Bilateral procedure modifier – 50

• Role-based modifiers – e.g., 62 (two surgeons), 80 (assistant surgeon), 82 (assistant surgeon when qualified resident not available), AS (non-physician surgical assistant)

• Multiple or distinct procedure modifiers – e.g., 51 (multiple procedures), 59 (distinct procedural service)

• Global modifiers – e.g., 58 (staged or related procedure), 78 (return to operating room for related procedure), 79 (unrelated procedure or service)

This is not an all-inclusive list of modifiers that may be appropriately applied to unlisted CPT codes. For complete and up-to-date information, one should refer to current CPT guidelines and payer-specific policies.

Please note: Modifiers that describe an alteration of a service or procedure, such as modifier 52 (reduced services), are not appropriate for use with unlisted codes. The same applied to modifier 22 (increased procedural services).

*This response is based on the best information available as of 9/22/25.

E/M Coding Based on Time

Question:

When choosing the level of E/M we are confused about the History and Exam. If we choose a level of E/M based on time, does this time count toward total time, or is it only time spent on MDM?

Answer:

When choosing a level of E/M based on time, CPT identifies the following activities as those that may contribute to total time on the date of service. Obtaining the history and performing the exam contribute to the total time for code selection. These activities occur on the same day as the actual encounter to contribute to the level of service. The following services must be performed and documented by the practitioner. Ancillary staff time does not count.

Physician/other qualified health care professional time includes the following activities when performed:

• preparing to see the patient (e.g., review of tests);

• obtaining and/or reviewing separately obtained history;

• performing a medically appropriate examination and/or evaluation;

• counseling and educating the patient/family/ caregiver;

• ordering medications, tests, or procedures;

• referring and communicating with other health care professionals (when not separately reported);

• documenting clinical information in the electronic or other health record;

• independently interpreting results (when not separately reported) and communicating results to the patient/family/caregiver; and

• care coordination (when not separately reported).

Source: CPT Assistant April 2022*This response is based on the best information available as of 9/25/25.

Documenting Mohs Surgery

Question:

What should be documented in my note to support billing for Mohs surgery?

Answer:

This is a great question. To support Mohs surgery, comprehensive documentation should include several key components:

Pre-operative Documentation:

• Detailed pathology report confirming the skin cancer diagnosis (basal cell carcinoma, squamous cell carcinoma, etc.)

• Clinical photography showing the lesion's size, location, and characteristics

• Patient history including previous treatments, recurrences, or incomplete excisions

• Documentation of high-risk features (location on face/genitals, size >2cm on trunk/extremities or >1cm on face, aggressive histologic subtypes, perineural invasion)

• Medical necessity justification explaining why Mohs is preferred over standard excision

Operative Documentation:

• Detailed operative report describing the procedure, number of stages required, and final defect size

• Stage-by-stage documentation with tissue mapping and frozen section results

• Real-time photographs of each stage and the final defect

• Pathology reports for each Mohs stage confirming margin status

• Documentation of any complications or unusual findings

Post-operative Documentation:

• Reconstruction plan and methods used for wound closure

• Post-operative care instructions and follow-up schedule

• Final pathology confirming complete tumor removal

• Patient education materials provided

Insurance and Administrative:

• Prior authorization if required by the insurance plan

• Appropriate CPT codes (17311-17315 for Mohs surgery stages, plus reconstruction codes)

• Documentation supporting medical necessity, particularly for lesions that might be considered for standard excision

This thorough documentation ensures proper patient care, supports insurance reimbursement, and provides a complete medical record for future reference.

*This response is based on the best information available as of 8/28/25.

Measuring an ED&C

Question:

How are measurements determined for electrodessication and curettage (ED&C) procedures for destruction of malignant lesions CPT codes 17260-17286? Is it the lesion only or the lesion after curettage?

Answer:

Great question—this detail can make a big difference in accurate coding. For CPT codes 17260–17286, which describe destruction of malignant skin lesions (including methods like electrodessication and curettage), the measurement is based on the lesion diameter prior to the procedure, not the size of the wound or defect after curettage.

Here’s what’s key:

• Measure the lesion itself before any destruction technique is applied.

• Do not measure the post-procedure defect or area of tissue removed.

• The method of destruction (e.g., ED&C, cryosurgery, laser) does not affect code selection—only anatomic location and lesion size matter.

*This response is based on the best information available as of 8/14/25.