Wiki New Patient visit and procedure


Knoxville, TN
Best answers
Can someone help with this one? I have a new patient visit with two procedures. Do you think there is enough documentation to support both the e&m plus the two procedures. Insurance is medicare

cc:Lesion on forehead
HPI: 73 y/o man. seen here for the first time today. he has a history of squamous cell carcinoma on the left arm and basal cell carcinoma on the right forehead, near the temple- both in January. He says he has a lesion on his forehead for about a one year. He thinks it may be another skin cancer. He would also like a full skin check today. He uses a hat for sun protection.

ROS: no rash

PMH: CAD status post CABG; history of carcinomas as noted
Meds: tylenol, tramadol, simvastatin
Family: no family history of skin cancer
Social: patient is a veterinarian and is married.

PE: General: awake, alert, and oriented. No acute distress
Skin: examination of the scalp, face, neck, chest, back, abd, rue, lue, rle, lle, digits, nails, and buttocks. reveals a pink papule with pearly edges and telangiectasis going through it on the left forehead. Lateral to the patient's right eye, there is a slightly yellowish skin colored papule consistent with sebaceous hyperplasia. He has a scaly-ill defined pink papule on his left ear.

1. Left forehead skin lesion with history of basal cell carcinoma, likely basal cell carcinoma; biopsy performed
Procedure note: informed consent obtained. area cleaned with alcohol and then injected with 1% lidocaine with epinephrine. The area was then cleansed with hibiclens. A biopsy performed with flexible Gillette blade. hemostasis was achieved with aluminum chloride. dressed with antibiotic ointment and band aid.
2. actinic keratosis-left ear. treated with cryotherapy freeze thaw freeze. wound care discussed.

E&M - 99202 -25?