CoderinJax
Guru
SUBJECTIVE: Patient is a 38-year-old here for follow-up to biopsy taken from axilla, face, scalp and eyelid. Patient states no problems with biopsy sites. Patient does have a keloid on chest they would like treated. Patient's medications have been reviewed. PATIENT IS ALLERGIC TO IODINE. Has no history of skin cancer.
OBJECTIVE: Physical examination reveals four well healed biopsy sites on the axilla, eyelid, and
cheek. The chest reveals a pink keloidal papule. -
ASSESSMENT:
1. Keloid.
2. Verruca vulgaris, biopsy-proven benign.
3. ISK, biopsy-proven benign.
4. Clark's nevus, biopsy-proven.
PLAN:
1. The 11 mm Clark's nevus from axilla was re-shaved for margins. After discussion with the patient, it was determined that the best course of action will be a shave excision. The risks and benefits of the procedures were outlined and included scarring approx the size of the lesion, infection, and bleeding. The patient clearly understood that a scar would be present and will be permanent. The patient was also clearly told that the specimen will be sent for pathologic evaluation. The area was prepped with alcohol and intralesional Xylocaine with epinephrine was used for local anesthesia. The lesion was completely excised through the superficial or mid dermis and the base was chemically cauterized with Monsel solution. The patient was given wound care instructions of twice daily dressing changes with hydrogen peroxide and Polysporin and was told to call us if bleeding occurred for more than five minutes while apply pressure or if significant swelling, redness and pain occurred.
2 Intralesional Kenalog 1.25 mg/cc, 0.1 cc injected into keloid. Post op care discussed with the patient3. No treatment for SK or verruca.
4. Side effects, risks and benefits were discussed with the patient including scarring and dyspigmentation in great detail.
5. ABCDs of changing skin lesions discussed with the patient. The patient is to wear sunscreen at all times.
6. RTC six months.
[SIZE="3]Hi! I need some help with this Op report.
For #1 the office billed CPT 11602, yet I do not see any mention that it was malignant, nor do I see a size listed of the lesion/margins. I see where it states 11mm on the first line in #1 of the Plan, which converts to 1.1 cm, but I don't see a breakdown of the lesion and margin. (IS THIS NECESSARY??) Also, the Path report is attached and states "excision of previously diagnosed Clark's Nevus w/ the margins free of tumor. There is residual scar present." So nothing to prove its malignancy.
For #2 the office billed 11900-59 and J3301, which I agree with.[/SIZE]I'm WAY NEW to Dermatology, so I could be way off..I'm open to any advice and recommendations!
OBJECTIVE: Physical examination reveals four well healed biopsy sites on the axilla, eyelid, and
cheek. The chest reveals a pink keloidal papule. -
ASSESSMENT:
1. Keloid.
2. Verruca vulgaris, biopsy-proven benign.
3. ISK, biopsy-proven benign.
4. Clark's nevus, biopsy-proven.
PLAN:
1. The 11 mm Clark's nevus from axilla was re-shaved for margins. After discussion with the patient, it was determined that the best course of action will be a shave excision. The risks and benefits of the procedures were outlined and included scarring approx the size of the lesion, infection, and bleeding. The patient clearly understood that a scar would be present and will be permanent. The patient was also clearly told that the specimen will be sent for pathologic evaluation. The area was prepped with alcohol and intralesional Xylocaine with epinephrine was used for local anesthesia. The lesion was completely excised through the superficial or mid dermis and the base was chemically cauterized with Monsel solution. The patient was given wound care instructions of twice daily dressing changes with hydrogen peroxide and Polysporin and was told to call us if bleeding occurred for more than five minutes while apply pressure or if significant swelling, redness and pain occurred.
2 Intralesional Kenalog 1.25 mg/cc, 0.1 cc injected into keloid. Post op care discussed with the patient3. No treatment for SK or verruca.
4. Side effects, risks and benefits were discussed with the patient including scarring and dyspigmentation in great detail.
5. ABCDs of changing skin lesions discussed with the patient. The patient is to wear sunscreen at all times.
6. RTC six months.
[SIZE="3]Hi! I need some help with this Op report.
For #1 the office billed CPT 11602, yet I do not see any mention that it was malignant, nor do I see a size listed of the lesion/margins. I see where it states 11mm on the first line in #1 of the Plan, which converts to 1.1 cm, but I don't see a breakdown of the lesion and margin. (IS THIS NECESSARY??) Also, the Path report is attached and states "excision of previously diagnosed Clark's Nevus w/ the margins free of tumor. There is residual scar present." So nothing to prove its malignancy.
For #2 the office billed 11900-59 and J3301, which I agree with.[/SIZE]I'm WAY NEW to Dermatology, so I could be way off..I'm open to any advice and recommendations!
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