I started an audit and I have provider who keeps billing a 99214 w/69100, but per documentation I'm leaning more to a 99213, can someone verify with me please?? Having concerns in the Physical exam where it looks more of a expanded exam instead of a detailed exam and missing to put location of where the findings are located. HELP please!
SUBJECTIVE:
History of Present Illness:
xxxxx is a 68 y.o. male is seen today for follow up skin exam.
Hx of NMSC, AK.
Rough spots on nose; rough bumps on feet.
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REVIEW OF SYSTEMS:
SKIN: No other new or changing moles.
HEME/LYMPH: No new or enlarging lumps or bumps.
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OBJECTIVE:
GEN: appears well groomed; alert; oriented; pleasant
SKIN: Detailed exam of scalp, face including lids and lips, ears, neck, chest, abdomen, back, buttocks, upper and lower extremities including digits completed and are normal except:
1. Left antihelix- erythem macule -Ear
2. AKs nose
3. Stucco keratoses ankles/feet
4. Nevi - missing location
5. SKs - missing location
6. Angiomas - missing location
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ASSESSMENT/PLAN:
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1. BCC/SCC(ears). Discussed tx options and risks. Shave biopsy of the lesion noted above to confirm diagnosis. The procedure, risks, benefits, alternatives and expected outcomes were discussed with the patient and consent was obtained. Patient identified, procedure verified, site identified and verified. Patient and staff present in agreement. Area prepped with alcohol and anesthetized using 1% lidocaine. Shave of lesion performed. Base cauterized and bandaging applied. Specimen sent to pathology. Patient instructed in routine post-op care.
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2. AKs. Discussed tx options and risks. He prefers efudex- apply bid x 3 weeks; reviewed how to use, sun protection, toxic to pets.
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3. Stucco keratoses. Discussed tx options and risks. Benign. Am lactin cream.
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4. Nevi. Discussed tx options and risks. Stable per pt; ABCDEs reviewed. Rec self exams and call with concerns.
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5. SKs. Discussed tx options and risks. Benign. Asymptomatic. Reassurance. Call with concerns.
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6. Angiomas. Discussed tx options and risks. Benign. Asymptomatic. Reassurance. Call with concerns.
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Discussed the signs and symptoms of skin cancers as well as reviewed sun protection.
SUBJECTIVE:
History of Present Illness:
xxxxx is a 68 y.o. male is seen today for follow up skin exam.
Hx of NMSC, AK.
Rough spots on nose; rough bumps on feet.
*
--------------------------------------------------------------------------
REVIEW OF SYSTEMS:
SKIN: No other new or changing moles.
HEME/LYMPH: No new or enlarging lumps or bumps.
*
--------------------------------------------------------------------------
*
OBJECTIVE:
GEN: appears well groomed; alert; oriented; pleasant
SKIN: Detailed exam of scalp, face including lids and lips, ears, neck, chest, abdomen, back, buttocks, upper and lower extremities including digits completed and are normal except:
1. Left antihelix- erythem macule -Ear
2. AKs nose
3. Stucco keratoses ankles/feet
4. Nevi - missing location
5. SKs - missing location
6. Angiomas - missing location
*
--------------------------------------------------------------------------
ASSESSMENT/PLAN:
*
1. BCC/SCC(ears). Discussed tx options and risks. Shave biopsy of the lesion noted above to confirm diagnosis. The procedure, risks, benefits, alternatives and expected outcomes were discussed with the patient and consent was obtained. Patient identified, procedure verified, site identified and verified. Patient and staff present in agreement. Area prepped with alcohol and anesthetized using 1% lidocaine. Shave of lesion performed. Base cauterized and bandaging applied. Specimen sent to pathology. Patient instructed in routine post-op care.
*
2. AKs. Discussed tx options and risks. He prefers efudex- apply bid x 3 weeks; reviewed how to use, sun protection, toxic to pets.
*
3. Stucco keratoses. Discussed tx options and risks. Benign. Am lactin cream.
*
4. Nevi. Discussed tx options and risks. Stable per pt; ABCDEs reviewed. Rec self exams and call with concerns.
*
5. SKs. Discussed tx options and risks. Benign. Asymptomatic. Reassurance. Call with concerns.
*
6. Angiomas. Discussed tx options and risks. Benign. Asymptomatic. Reassurance. Call with concerns.
*
Discussed the signs and symptoms of skin cancers as well as reviewed sun protection.
