veloso
Expert
Can this encounter qualifies for 99203? Thanks.
Chief Complaint(s):
dry skin of feet.
HPI:
Clinic Visit
54 year old male presents with c/o dry and itching skin on the bottom of the feet x few months. patient denies trauma to the feet.
Current Medication:
Medical History:
No Medical History documented.
Allergies/Intolerance:
N.K.D.A.
ROS:
Objective:
Vitals:
Past Results:
Examination:
Vascular
PEDAL PULSES Dorsalis pedis, +1/4, bilateral, Posterior tibial, +1/4, bilateral. CAPILLARY REFILL TIME 2# of seconds x 10 toes. TEMPERATURE GRADIENT WNLs, bilaterally.
Dermatology
SKIN FINDINGS: positive severe,dry,scaling,pruritic,cracking sin plantarlly RT> LT,positive severe maceration of all web spaces RT>LT foot,positive mild malodor b/l feet.
Assessment:
Assessment:
Tinea pedis - 110.4 (Primary)
Plan:
Treatment:
Tinea pedis
proper foot care and hygiene instructed to patient,prescription for oxistat 1 % cream BID
Procedures:
Immunizations:
Diagnostic Imaging:
Lab Reports:
Next Appointment:
4 Weeks (Reason: follow up)
Billing Information:
Visit Code:
99203 PODIATRY Office Visit, New Pt., Level 3.
Chief Complaint(s):
dry skin of feet.
HPI:
Clinic Visit
54 year old male presents with c/o dry and itching skin on the bottom of the feet x few months. patient denies trauma to the feet.
Current Medication:
Medical History:
No Medical History documented.
Allergies/Intolerance:
N.K.D.A.
ROS:
Objective:
Vitals:
Past Results:
Examination:
Vascular
PEDAL PULSES Dorsalis pedis, +1/4, bilateral, Posterior tibial, +1/4, bilateral. CAPILLARY REFILL TIME 2# of seconds x 10 toes. TEMPERATURE GRADIENT WNLs, bilaterally.
Dermatology
SKIN FINDINGS: positive severe,dry,scaling,pruritic,cracking sin plantarlly RT> LT,positive severe maceration of all web spaces RT>LT foot,positive mild malodor b/l feet.
Assessment:
Assessment:
Tinea pedis - 110.4 (Primary)
Plan:
Treatment:
Tinea pedis
proper foot care and hygiene instructed to patient,prescription for oxistat 1 % cream BID
Procedures:
Immunizations:
Diagnostic Imaging:
Lab Reports:
Next Appointment:
4 Weeks (Reason: follow up)
Billing Information:
Visit Code:
99203 PODIATRY Office Visit, New Pt., Level 3.