diagnosis - Could I get some opinions please?

solocoder

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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.
 

CodingKing

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I just want to bang my head against the wall when I see a physician document a history of amputations. Its not a history of if you currently have the condition so you cant code acquired absence of any body parts. since its a history of, it must have been reattached ;)

Maybe Z87.2 - Personal history of diseases of the skin and subcutaneous tissue
 
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