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A patient is seen for a routine follow-up of ongoing problems (diabetes, hypertension). During the visit the physician looks at a couple of lesions the patient is concerned about. It is decided that the patient should come back one week later to address the removal of the skin lesions. The patient returns and is prepped for the removal of the lesions. One lesion measuring .4 cm is removed from her arm and another lesion measuring .65 is removed from her neck. The correct billing for the second visit when the lesions are removed should be:

Answer: c

The decision to have the patient return in one week for the lesion removal was made at the previous visit. The patient has returned for the sole purpose of having the lesions removed and that is the only service rendered and documented. The codes 11400 and 11421 accurately describe the location and size of the lesions removed. An E/M visit code would not be billed unless there was a separately identifiable service rendered and documented. In this case there was not.

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