solocoder
Expert
Could I get some opinions please? What ICD 10 code/codes would you assign to this visit? I'm thinking callus L84 and maybe a couple of personal history codes? Or could the personal history codes be listed first? Wouldn't that make it a preventive visit?
Any thoughts are greatly appreciated.
Patient presents to the clinic today for a follow up.* He has a history of multiple digital ulcerations and amputations.* He has remained wound free.* He did undergo a right TKA and is quite pleased.* He is hoping to have his left knee done in the fall sometime.
Neurovascular status is unchanged.
All ulcerations remain healed.
There is a superficial callus noted on the dorsal aspect of the right fifth toe.
A small shallow callus is noted sub 1 on the left foot. *
There are no pre ulcerative calluses.
There are no orthopedic changes.
Assessment: *
History of bilateral foot ulcers
Plan:
Patient is advised to watch for signs of re-occurrence of any ulcerations.
Continue padding and pumice stone as needed.
Follow up in two to three months.
Any thoughts are greatly appreciated.
Patient presents to the clinic today for a follow up.* He has a history of multiple digital ulcerations and amputations.* He has remained wound free.* He did undergo a right TKA and is quite pleased.* He is hoping to have his left knee done in the fall sometime.
Neurovascular status is unchanged.
All ulcerations remain healed.
There is a superficial callus noted on the dorsal aspect of the right fifth toe.
A small shallow callus is noted sub 1 on the left foot. *
There are no pre ulcerative calluses.
There are no orthopedic changes.
Assessment: *
History of bilateral foot ulcers
Plan:
Patient is advised to watch for signs of re-occurrence of any ulcerations.
Continue padding and pumice stone as needed.
Follow up in two to three months.
