Routine Visit or Specific Complaint
You must follow the normal office visit procedure as follows:
- Document a Reason for Visit
- Fill in the appropriate History of Present Illness (HPI) template
- Complete a Review of Systems
- Perform a Physical Examination
A patient who has come in to address a specific complaint such as acne, rash, warts, or lesions, might require a biopsy or non-surgical treatment. Based on the results of the skin examination, you may choose to schedule or perform any of the following:
- Biopsy to rule out skin cancer.
- Cryosurgery to treat actinic keratosis, seborrheic keratosis, or viral wart.
- Blue light (photodynamic) treatment for actinic keratosis.
- Topical treatment for eczema, certain warts, actinic keratosis, or certain basal and squamous cell cancers. These findings also may require a biopsy.
As a provider, your actions depend on whether you intend to bill for an office visit, a procedure, or both. If you plan to bill the patient for an office visit, you can select the Office Visit visit type. In addition, you must do the other steps that you normally perform for an office visit, including the reason for visit, HPI, review of systems, physical examination, assessment, and so on.
If you expect to perform only a procedure, and do not want to go through all the steps to bill for an office visit, then you can select the Surgical Visit visit type, even for non-surgical procedures, and document the minimum information related to office visits.