KristieStokesCPC
Expert
SUBJECTIVE:
CC:
Mr. X is a 76-year-old male. He is here for skin tag removal.
Current Problems:
Atypical mole
Congestive heart failure
Hip pain
Osteoarthritis
Other primary cardiomyopathy
Immunizations:
None
Allergies:
Morphine:
Codeine:
Lortab:
Cipro:
Current Medications:
Coreg 25mg Tablet Take 1 tablet(s) by mouth bid
Lasix 40mg Tablet Take 1 tablet(s) by mouth bid
Prinivil 20mg Tablet Take 1 tablet(s) by mouth twice daily
Ultram 50mg Tablet take 1-2 po q6-8hrs
Darvocet-N 100 100mg/650mg Tablet one po as needed for pain q 8 hours
Allopurinol 100mg Tablet Take 1 tablet(s) by mouth daily
Flagyl 500mg Tablet Take 1 tablet(s) by mouth tid for 10 days
Prilosec 20mg Capsules, Extended Release Take 1 capsule(s) by mouth daily
OBJECTIVE:
Vitals:
Current: 7/22/2008 4:52:44 PM
Ht: 73.2 inches; Wt: 270 lbs; BMI: 35.43
T: 97.6 F (oral); BP: 95/55 mm Hg (left arm, sitting); P: 69 bpm (left arm (BP Cuff), sitting); R: 16 bpm
Procedures:
Atypical mole
Procedure Note:
Informed consent obtained in writing. He expresses understanding that a scar may remain after the lesion is removed. Sterile technique is observed.
Benign appearing lesion #1 is located on right lower lateral thoracic. The method of removal is excision. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. Hemostasis is achieved with cautery. The specimen is sent for pathology review.
Benign appearing lesion #2 is a seborrheic keratosis located on right upper lateral thoracic. The method of removal is excision. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. The wound is closed with 3 simple interrupted stitch(es) using 4-0 Ethilon. The specimen is sent for pathology review.
Lesion #3 is round brown with white outer border, roots - came out in ball - center of back. The method of removal is excision. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
Benign Lesion #4 is a seborrheic keratosis located on mid back. The method of removal is shave removal. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
Benign Lesion #5 is a seborrheic keratosis located on mid back. The method of removal is shave removal. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. Hemostasis is achieved with application of pressure. The specimen is not sent for pathology review, as it is clearly benign.
Congenital accessory skin tags
Procedure Note:
Informed consent obtained in writing. He expresses understanding that a scar may remain after the lesion is removed. Sterile technique is observed. Multiple skin tags are located left side of scalp (in hair) above left ear. A total of one skin tag(s) removed today. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. The method of removal is shave excision. Hemostasis is achieved with cautery.
ASSESSMENT:
238.2 Atypical mole
757.39 Congenital accessory skin tags
PLAN:
Atypical mole
Orders:
Excision, benign lesion, except skin tag, trunk, arms, legs; lesion diameter 0.6 to 1.0 cm
A4550 Surgical trays (x1)
Excision, benign lesion, except skin tag, trunk, arms, legs; lesion diameter 1.1 to 2.0 cm
A4550 Surgical trays (x1)
Shaving of epidermal or dermal lesion, single lesion, trunk, arm, legs; lesion diameter 1.1 to 2.0 c
Shaving of epidermal or dermal lesion, single lesion, trunk, arm, legs; lesion diameter 0.6 to 1.0 c
Congenital accessory skin tags
Orders:
Removal of skin tags, multiple fibrocutaneous tags, any area; (initial 1-15)
CHARGE CAPTURE:
Primary Diagnosis:
238.2 Atypical mole
Orders:
99211 Office/outpatient visit; established patient, level 1
757.39 Congenital accessory skin tags
I think it would code:
17110
11401
11402
11301
11302
no office visit....
Please help, I'm confused
Thanks
Kristie Stokes CPC-A
CC:
Mr. X is a 76-year-old male. He is here for skin tag removal.
Current Problems:
Atypical mole
Congestive heart failure
Hip pain
Osteoarthritis
Other primary cardiomyopathy
Immunizations:
None
Allergies:
Morphine:
Codeine:
Lortab:
Cipro:
Current Medications:
Coreg 25mg Tablet Take 1 tablet(s) by mouth bid
Lasix 40mg Tablet Take 1 tablet(s) by mouth bid
Prinivil 20mg Tablet Take 1 tablet(s) by mouth twice daily
Ultram 50mg Tablet take 1-2 po q6-8hrs
Darvocet-N 100 100mg/650mg Tablet one po as needed for pain q 8 hours
Allopurinol 100mg Tablet Take 1 tablet(s) by mouth daily
Flagyl 500mg Tablet Take 1 tablet(s) by mouth tid for 10 days
Prilosec 20mg Capsules, Extended Release Take 1 capsule(s) by mouth daily
OBJECTIVE:
Vitals:
Current: 7/22/2008 4:52:44 PM
Ht: 73.2 inches; Wt: 270 lbs; BMI: 35.43
T: 97.6 F (oral); BP: 95/55 mm Hg (left arm, sitting); P: 69 bpm (left arm (BP Cuff), sitting); R: 16 bpm
Procedures:
Atypical mole
Procedure Note:
Informed consent obtained in writing. He expresses understanding that a scar may remain after the lesion is removed. Sterile technique is observed.
Benign appearing lesion #1 is located on right lower lateral thoracic. The method of removal is excision. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. Hemostasis is achieved with cautery. The specimen is sent for pathology review.
Benign appearing lesion #2 is a seborrheic keratosis located on right upper lateral thoracic. The method of removal is excision. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. The wound is closed with 3 simple interrupted stitch(es) using 4-0 Ethilon. The specimen is sent for pathology review.
Lesion #3 is round brown with white outer border, roots - came out in ball - center of back. The method of removal is excision. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
Benign Lesion #4 is a seborrheic keratosis located on mid back. The method of removal is shave removal. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
Benign Lesion #5 is a seborrheic keratosis located on mid back. The method of removal is shave removal. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. Hemostasis is achieved with application of pressure. The specimen is not sent for pathology review, as it is clearly benign.
Congenital accessory skin tags
Procedure Note:
Informed consent obtained in writing. He expresses understanding that a scar may remain after the lesion is removed. Sterile technique is observed. Multiple skin tags are located left side of scalp (in hair) above left ear. A total of one skin tag(s) removed today. Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine. The method of removal is shave excision. Hemostasis is achieved with cautery.
ASSESSMENT:
238.2 Atypical mole
757.39 Congenital accessory skin tags
PLAN:
Atypical mole
Orders:
Excision, benign lesion, except skin tag, trunk, arms, legs; lesion diameter 0.6 to 1.0 cm
A4550 Surgical trays (x1)
Excision, benign lesion, except skin tag, trunk, arms, legs; lesion diameter 1.1 to 2.0 cm
A4550 Surgical trays (x1)
Shaving of epidermal or dermal lesion, single lesion, trunk, arm, legs; lesion diameter 1.1 to 2.0 c
Shaving of epidermal or dermal lesion, single lesion, trunk, arm, legs; lesion diameter 0.6 to 1.0 c
Congenital accessory skin tags
Orders:
Removal of skin tags, multiple fibrocutaneous tags, any area; (initial 1-15)
CHARGE CAPTURE:
Primary Diagnosis:
238.2 Atypical mole
Orders:
99211 Office/outpatient visit; established patient, level 1
757.39 Congenital accessory skin tags
I think it would code:
17110
11401
11402
11301
11302
no office visit....
Please help, I'm confused
Thanks
Kristie Stokes CPC-A