Be careful when ICD-10 coding for "screening"
CPT has a series of “preventive screening” exams based on age. (These are in
the CPT code range of 99381-99387) Many patients are requesting the
dermatologists perform preventive screenings, as they believe that their
insurance covers it and they can see the dermatologist without a copy or
Dermatology is a problem-oriented specialty. Many carriers, including Medicare,
don't permit dermatologists to perform preventive visits or wellness exams,
even if it's for a screening for malignant neoplasms. Preventive visits are
typically performed by broader specialists like Family Practitioners, OBGYNs,
and Internal Medicine specialists. For example, a family practitioner may
perform a general full-body exam as part of a series of other checks during an
annual physical, and then coordinate further testing or appointments with
specialists for problems discovered during this "preventive visit."
We know that traditional Medicare will not cover “screening exams” for dermatologists. However, some commercial carriers/plans will cover it. Some commercial carriers will follow the CPT rules and allow both the screening CPT code and an E/M with modifier 25 (if a significant problem is identified). Some plans cover only one or the other.
Here is a CMS Guide to Preventive Services... you notice that "Skin Cancer Screening" or "Skin Exams" are not covered services under Preventive Services!!!!!
However, we are starting to see an very slight increase (but not many) in the number of reports of commercial carriers allowing screenings by specialists, like dermatologists. However, the problem of “coverage” is compounded by the widespread discrepancies from carrier to carrier and even plan to plan on which types of screenings are covered. Many carriers and plans still only permit screenings by primary care providers.
For example, here is Cigna's Position On Screening Exams - not eligible for
And here is United Healthcare's Position on Screening Exams - not eligible
CPT states the following under “Preventive Medicine Services”.
“If an abnormality is encountered or a preexisting problem is addressed in
the course of performing this preventive medicine evaluation and management
service, and if the problem or abnormality is significant enough to require the
additional work of a problem-oriented E/M service, then the appropriate
Office/Outpatient E/M code 99201 – 99215 should also be reported. Modifier
25 should be added to the Office/Outpatient code to indicate that a
significant, separately identifiable evaluation and management service was
provided on the same day as the preventive medicine service. The
appropriate preventive medicine service is additionally reported.
An insignificant or trivial problem/abnormality that is encountered in the
process of performing the preventive medicine evaluation and management service
and which does not require additional work and the performance of the key
components of a problem-oriented E/M service should not be reported.”
Does the plan cover it or not?
We highly recommend that providers and billers verify with each carrier whether
they cover preventive screenings for dermatology. As the reliability of
information provided over the phone by carrier reps is questionable (and not
enforceable in an appeal), we highly recommend that you obtain written
verification of coverage or find out where to verify coverage policies online
with each carrier. Do this for each carrier and each plan within that carrier.
Screenings may be covered by some plans and not with others.
Find out how they want you to bill it (CPT code) and what diagnosis code to use
for the screening if nothing is found!
Once you have determined if the patient’s insurance coverage will allow for a
screening, the question becomes how to code the diagnosis for “screening
In ICD-10, a code exists for “screening of malignant neoplasms”
Z12.83 Encounter for screening of malignant
Use additional: Use additional code to identify any
family history of malignant neoplasm (Z80.-)
Excludes1: encounter for diagnostic examination-code to
sign or symptom
We know that many carriers will deny E/M visits and screening codes with
Z12.83, especially if Z12.83 is the only diagnosis code associated with the
screening or E/M code. Dermatologists should proceed with caution when using
Z12.83 as a primary diagnosis for E/M visits. Here’s why…
The notes in the Z12 header also give us an idea of what should be done...
(e.g., encounter for diagnostic examination and code to sign or symptom). So
code what is found, even if it's not necessarily symptomatic!
You may be better off using a personal history of ____ code (if it exists for
the patient) or code based on conditions discovered during the exam, even if
asymptomatic or not requiring treatment. Perhaps the patient has dry skin, some
normal looking melanocytic nevi (moles), and a skin tag or two. Code those!
Again, if a problem is discovered that requires treatment, you may be able to
bill an E/M with modifier 25 (according to CPT), but as we have discussed
coverage of both the screening and E/M varies from carrier to carrier and plan
So what are some better choices?
If a patient comes in for their annual exam or semi-annual skin exam (or
screening), you have several choices on how to code the diagnosis for the
1. If the patient has a personal history of malignant
neoplasms, use one of the following codes as one of your diagnoses. This
justifies the medical necessity for the visit. In addition, code and bill for
anything you discover during the exam (even if asymptomatic). Melanocytic nevi
(dysplastic nevus) works if the patient has moles but aren't requiring
Z85.820 Personal history of malignant melanoma of skin
Z85.821 Personal history of Merkel cell carcinoma
Z85.828 Personal history of other malignant neoplasm of
Caveat: Please check with your carrier(s) to see
if they will accept a “Personal history of … (Z85.82?) or (Z86.?, Z87.?) code
as a diagnosis reported with the E/M code. Some carriers may also require an
additional diagnosis to be coded for other condition(s) discovered during the
exam (even if asymptomatic).
2. If the patient has no prior personal history, and a
malignant neoplasm is discovered, code the appropriate ICD-10 neoplasm code for
any procedures performed on the lesion that day (i.e., biopsy, excision, shave
removal, destruction, Mohs, etc.).
Note: The E/M is included in reimbursement of procedures with 0 or 10 postop
days (including those performed on new patients). A separate E/M may be billed
if it is indeed separate and identifiable from the procedure and modifier 25
(or 57 in some cases) is appended.
3. The patient may have melanocytic nevi (normal
appearing moles) that aren't of concern to the provider during the visit. Maybe
that was the patient's primary concern when they came in. (e.g., "I have a
lot of moles. I've never been to the dermatologists, and I'd like you to check
me over to make sure I don't have any skin cancer.") Then use the
D22.0?-D22.9? series by body site for melanocytic nevus (dysplastic nevus). You
only need to add one or two locations to the E/M visit when billing, however
the chart note should document and reflect all areas/moles examined. Many
carriers are even requiring the use of body diagrams and are denying appeals
when just locations such as “face” are noted for neoplasms! Check your carrier
medical policies and bulletins!
4. The patient might possibly have potential AKs or skin
tags that will be monitored in the future. Maybe the patient has dry skin, or
acne that was discovered and discussed with the patient. There are many types
of findings that could be noted during the full-body exam. It's rare for a
patient to have flawless skin with absolutely nothing to document. That is
generally reserved for newborn babies. You don't necessarily have to treat
something, to be able to attach it to an E/M. So if the patient presents with
no neoplasms of concern, then pick another documented condition from the chart
note and attach it to the E/M.
5. You may consider also adding one of the other
"personal history codes" if the patient has them. This helps justify
medical necessity. But note, the "personal history" codes, alone, may
not be sufficient alone for billing an E/M. Check with your carrier.
Other Personal history codes include:
Z86.008 Personal history of in-situ neoplasm of other
Z86.018 Personal history of other benign neoplasm
Z87.2 Personal history of diseases of the skin and
It is our opinion that the screening CPT codes and ICD-10 code Z12.83 should be
treated with caution.