We are a Dermatology clinic and will have patients come in for a complete skin exam. Example below. Can this be a CC? How would you code this and what audit findings would you report back to the provider?
CC/HPI: He is a 63 year old NEW (former 2014) patient with NO personal or family history of melanoma here to reestablish care as encouraged by his wife who was concerned of a bump or zit on his nose that is not healing. It has bled in the past. Full Body Skin Exam, last 1/2014.
ROS: No additional skin complaints, No constitutional symptoms
Exam: Scalp, Head, Neck, Chest, Abdomen, Buttocks, Back, Right Upper extremity, Left Upper extremity, Right lower extremity, Left lower extremity, Digits/Nails, Eyes/Eyelids, ENT (lips) and Genitalia.
A/P: 1. Nevi, benign (entire body including genitalia) - Pt reassured. 2. Neoplasm of uncertain behavior - r/o BCC (md tip of nose). Biopsy today - tangential
Thanks! Alicia
CC/HPI: He is a 63 year old NEW (former 2014) patient with NO personal or family history of melanoma here to reestablish care as encouraged by his wife who was concerned of a bump or zit on his nose that is not healing. It has bled in the past. Full Body Skin Exam, last 1/2014.
ROS: No additional skin complaints, No constitutional symptoms
Exam: Scalp, Head, Neck, Chest, Abdomen, Buttocks, Back, Right Upper extremity, Left Upper extremity, Right lower extremity, Left lower extremity, Digits/Nails, Eyes/Eyelids, ENT (lips) and Genitalia.
A/P: 1. Nevi, benign (entire body including genitalia) - Pt reassured. 2. Neoplasm of uncertain behavior - r/o BCC (md tip of nose). Biopsy today - tangential
Thanks! Alicia