CPT Knowledgebase - Dec 8, 2022

A 50-year-old established male patient presents for his annual skin examination pursuant to a history of squamous cell carcinoma (SCC) on the right forehead treated 5 years ago. The patient has no concerns today apart from a few scattered brown spots on the trunk that end up being benign nevi and seborrheic keratoses. A complete skin examination is performed, and diagnoses for the visit include benign nevi on the trunk, seborrheic keratoses, and his history of SCC. Sun protection, including the use of SPF 30 or higher sunscreen, and self-skin exams are recommended treatments. In addition to the history of skin cancer: The patient presents with two or more self-limited minor problems (benign nevi and seborrheic keratoses), which qualifies this element as low complexity; It is not documented that there were any data reviewed, which qualifies this element as minimal; and It is recommended that the patient use over-the-counter (OTC) broad-spectrum sunscreen, which qualifies the risk of complications and/or morbidity or mortality of patient management as low. What is the appropriate E/M level for this service?

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