KristieStokesCPC
Expert
SUBJECTIVE:
CC:Ms. X is a 56-year-old female.
Past Medical History / Family History / Social History:
Past Medical History:
Skin cancer: multiple basal cells have been excised;
Current Problems:
Basal cell carcinoma
Dupuytren's contracture
Lipoma, of skin and subcutaneous tissue, NEC
Unspecified skin lesion
Allergies:
Codeine:
Hydrocodone/Acetaminophen:
Current Medications:
Darvocet-N 100 Tablet Take 1 tablet(s) by mouth q 4 to 6 hr prn
Mobic 7.5mg Tablet Take 1 tablet(s) by mouth daily
OBJECTIVE:
Vitals:
Current: 4/10/2008 5:20:24 PM
Ht: 66 inches; Wt: 138 lbs; BMI: 22.27
T: 98.7 F (oral); BP: 126/74 mm Hg (left arm, sitting); P: 71 bpm (left arm (BP Cuff), sitting); R: 14 bpm
Procedures:
Basal cell carcinoma
Procedure Note:
Informed consent obtained in writing. She expresses understanding that a scar may remain after the lesion is removed. Sterile technique is observed.
Malignant Lesion #1 is a basal cell carcinoma located on left anterior shoulder. The lesion is removed by excision. Anesthesia was obtained with 1 cc of 1% lidocaine with epinephrine. The wound is closed with 6 simple interrupted stitch(es) using 4-0 Ethilon. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
Atypical skin lesion
Procedure Note:
Benign appearing lesion #1 is located on left posterior knee. The method of removal is excision. Anesthesia was obtained with 1 cc of 1% lidocaine with epinephrine. The wound is closed with 5 simple interrupted stitch(es) using 4-0 Ethilon. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
Atypical skin lesion
Procedure Note:
Benign appearing lesion #2 is right anterior lower leg. The method of removal is excision. Anesthesia was obtained with 1 cc of 1% lidocaine with epinephrine. The wound is closed with 5 simple interrupted stitch(es) using 4-0 Ethilon. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
Atypical skin lesion
Procedure Note:
Lesion #3 is mid anterior chest. The method of removal is excision. Anesthesia was obtained with 1 cc of 1% lidocaine with epinephrine. The wound is closed with 6 simple interrupted stitch(es) using 4-0 Ethilon. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
ASSESSMENT:
173.9 Basal cell carcinoma
238.2 Atypical skin lesion
238.2 Atypical skin lesion
238.2 Atypical skin lesion
PLAN:
Basal cell carcinoma
Orders:
Excision, malignant lesion, trunk, arms, legs; lesion diameter 0.6 to 1.0cm
Atypical skin lesion
Orders:
Excision, benign lesion, except skin tag, trunk, arms, legs; lesion diameter 0.6 to 1.0 cm
A4550 Surgical trays (x1)
Atypical skin lesion
Orders:
Excision, benign lesion w/margins (not skin tag), trunk, arms, legs; excised diameter 0.6 to 1.0 cm
Atypical skin lesion
Orders:
Excision, benign lesion w/margins (not skin tag), trunk, arms, legs; excised diameter 0.6 to 1.0 cm
CHARGE CAPTURE:
Primary Diagnosis:
173.9 Basal cell carcinoma left anterior shoulder
Orders:
99211-51 Office/outpatient visit; established patient, level 1
11601 Excision, malignant lesion, trunk, arms, legs; lesion diameter 0.6 to 1.0cm
238.2 Atypical skin lesion posterior left knee
Orders:
11401 Excision, benign lesion, except skin tag, trunk, arms, legs; lesion diameter 0.6 to 1.0 cm
A4550 Surgical trays (x1)
238.2 Atypical skin lesion right anterior lower leg
Orders:
11401 Excision, benign lesion w/margins (not skin tag), trunk, arms, legs; excised diameter 0.6 to 1.0 cm
238.2 Atypical skin lesion anterior mid chest
Orders:
11401 Excision, benign lesion w/margins (not skin tag), trunk, arms, legs; excised diameter 0.6 to 1.0 cm
The provider doesn't want to charge the level 1 office visit, but other than that how would you code the rest of it?
Thank you
Kristie Stokes, CPC-A
CC:Ms. X is a 56-year-old female.
Past Medical History / Family History / Social History:
Past Medical History:
Skin cancer: multiple basal cells have been excised;
Current Problems:
Basal cell carcinoma
Dupuytren's contracture
Lipoma, of skin and subcutaneous tissue, NEC
Unspecified skin lesion
Allergies:
Codeine:
Hydrocodone/Acetaminophen:
Current Medications:
Darvocet-N 100 Tablet Take 1 tablet(s) by mouth q 4 to 6 hr prn
Mobic 7.5mg Tablet Take 1 tablet(s) by mouth daily
OBJECTIVE:
Vitals:
Current: 4/10/2008 5:20:24 PM
Ht: 66 inches; Wt: 138 lbs; BMI: 22.27
T: 98.7 F (oral); BP: 126/74 mm Hg (left arm, sitting); P: 71 bpm (left arm (BP Cuff), sitting); R: 14 bpm
Procedures:
Basal cell carcinoma
Procedure Note:
Informed consent obtained in writing. She expresses understanding that a scar may remain after the lesion is removed. Sterile technique is observed.
Malignant Lesion #1 is a basal cell carcinoma located on left anterior shoulder. The lesion is removed by excision. Anesthesia was obtained with 1 cc of 1% lidocaine with epinephrine. The wound is closed with 6 simple interrupted stitch(es) using 4-0 Ethilon. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
Atypical skin lesion
Procedure Note:
Benign appearing lesion #1 is located on left posterior knee. The method of removal is excision. Anesthesia was obtained with 1 cc of 1% lidocaine with epinephrine. The wound is closed with 5 simple interrupted stitch(es) using 4-0 Ethilon. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
Atypical skin lesion
Procedure Note:
Benign appearing lesion #2 is right anterior lower leg. The method of removal is excision. Anesthesia was obtained with 1 cc of 1% lidocaine with epinephrine. The wound is closed with 5 simple interrupted stitch(es) using 4-0 Ethilon. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
Atypical skin lesion
Procedure Note:
Lesion #3 is mid anterior chest. The method of removal is excision. Anesthesia was obtained with 1 cc of 1% lidocaine with epinephrine. The wound is closed with 6 simple interrupted stitch(es) using 4-0 Ethilon. Hemostasis is achieved with application of pressure. The specimen is sent for pathology review.
ASSESSMENT:
173.9 Basal cell carcinoma
238.2 Atypical skin lesion
238.2 Atypical skin lesion
238.2 Atypical skin lesion
PLAN:
Basal cell carcinoma
Orders:
Excision, malignant lesion, trunk, arms, legs; lesion diameter 0.6 to 1.0cm
Atypical skin lesion
Orders:
Excision, benign lesion, except skin tag, trunk, arms, legs; lesion diameter 0.6 to 1.0 cm
A4550 Surgical trays (x1)
Atypical skin lesion
Orders:
Excision, benign lesion w/margins (not skin tag), trunk, arms, legs; excised diameter 0.6 to 1.0 cm
Atypical skin lesion
Orders:
Excision, benign lesion w/margins (not skin tag), trunk, arms, legs; excised diameter 0.6 to 1.0 cm
CHARGE CAPTURE:
Primary Diagnosis:
173.9 Basal cell carcinoma left anterior shoulder
Orders:
99211-51 Office/outpatient visit; established patient, level 1
11601 Excision, malignant lesion, trunk, arms, legs; lesion diameter 0.6 to 1.0cm
238.2 Atypical skin lesion posterior left knee
Orders:
11401 Excision, benign lesion, except skin tag, trunk, arms, legs; lesion diameter 0.6 to 1.0 cm
A4550 Surgical trays (x1)
238.2 Atypical skin lesion right anterior lower leg
Orders:
11401 Excision, benign lesion w/margins (not skin tag), trunk, arms, legs; excised diameter 0.6 to 1.0 cm
238.2 Atypical skin lesion anterior mid chest
Orders:
11401 Excision, benign lesion w/margins (not skin tag), trunk, arms, legs; excised diameter 0.6 to 1.0 cm
The provider doesn't want to charge the level 1 office visit, but other than that how would you code the rest of it?
Thank you
Kristie Stokes, CPC-A