Question: A 17-year-old male presents with acneiform papules on his chin for 1 month. The patient had clear skin prior to starting football practice. The papules are under the area covered by his chin strap. The patient is diagnosed with acne due to physical occlusion from the chin strap. A prescription for topical benzoyl peroxide 5%/clindamycin 1% gel is provided. Potential side effects of prescribed medications are addressed, and skin care is discussed. The patient is reassured that the acne will likely resolve when the football season is over. What evaluation and management (E/M) code would be appropriate to report for this service? ...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This premium article focuses on selecting an appropriate evaluation and management code for a short clinical encounter involving acneiform papules associated with physical occlusion from sports equipment. It discusses how the documented history, risk, and management support the level of medical decision making, and it references CPT medical decision-making guidance and related errata for clarification. The piece is useful for coders, auditors, and clinicians who need to understand how documentation drives office visit level selection in a dermatology-related scenario.

Why This Topic Matters

Accurate E/M level selection depends on matching documentation to the medical decision-making elements and overall risk of the encounter. This article helps users understand how a common outpatient skin complaint can be coded when prescription management is involved and when official CPT guidance is referenced.

Codes Discussed

• CPT: 99203
• CPT: 99213

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