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How would you code this?

A

arrana

Guru
Local Chapter Officer
Messages
107
Podiatry is not my specialty, but I've been tasked with processing claims for submission, AND auditing the provider's documentation and coding. I have removed the PFSH (it was copy and pasted so is inadmissible anyway), otherwise the note is exactly how the provider wrote it.

How would you code/audit this visit?

Chief Complaints:
1. Pt. presents for 6 wk. f/u care for thick ingrown nails L foot. Pt. has been applying topical medication to affected nails twice a day..


Physical Examination:
Pt. has a thick ingrown Hallux nails. Pt. is applying Formula-3 medication to affected nails L Hallux.


Assessment:
1. Ingrowing nail - 703.0 (Primary)
2. Hypertrophy of nail - 703.8
3. Foot pain - 729.5
4. Dermatophytosis of foot - 110.4
5. Atherosclerosis of the extremities, unspecified - 440.20

Plan:
1. Ingrowing nail
Notes: Excision on nails border L Hallux. Pt. to continue apply Formula-3 to Hallux BID.


Follow Up: 6 Weeks, 2 Months

Thanks,
Arrana
 
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