kansasrhit2009
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Family Practice Clinic Note:
The patient presents and complains of a couple sites that are different on her incision. She had a cesarean section approximately 3 weeks ago. It is sore on the right side. She complains of pain. She is having to take Motrin and Norco for that.
O: Skin edges are all approximated nicely. There is one spot just to the left of midline that shows one area of a little bit of “proud tissue”. It is about 3 mm long. This is treated with silver nitrate. She tolerated that well. On the right side the little lump I can feel I think is subcutaneous sutures knot.
A: 1. SUBCUTANEOUS KNOT IN PFANNENSTIEL INCISION.
2. SMALL AREA OF PROUD TISSUE.
P: Use the silver nitrate as noted. Reassured her on the incision otherwise. At this point I do not think there is any evidence of a stitch abscess or extrusion. Did give her a prescription for more of her Motrin 800 mg #90 one refill 1 p.o. t.i.d. with food as needed. She will followup at 2 months for a routine postpartum exam. Just reassured her there is no dehiscence apparent.
How would you code with a CPT code?
For the ICD 9 I have-----674.34 and 701.5 but for the CPT code?
The patient presents and complains of a couple sites that are different on her incision. She had a cesarean section approximately 3 weeks ago. It is sore on the right side. She complains of pain. She is having to take Motrin and Norco for that.
O: Skin edges are all approximated nicely. There is one spot just to the left of midline that shows one area of a little bit of “proud tissue”. It is about 3 mm long. This is treated with silver nitrate. She tolerated that well. On the right side the little lump I can feel I think is subcutaneous sutures knot.
A: 1. SUBCUTANEOUS KNOT IN PFANNENSTIEL INCISION.
2. SMALL AREA OF PROUD TISSUE.
P: Use the silver nitrate as noted. Reassured her on the incision otherwise. At this point I do not think there is any evidence of a stitch abscess or extrusion. Did give her a prescription for more of her Motrin 800 mg #90 one refill 1 p.o. t.i.d. with food as needed. She will followup at 2 months for a routine postpartum exam. Just reassured her there is no dehiscence apparent.
How would you code with a CPT code?
For the ICD 9 I have-----674.34 and 701.5 but for the CPT code?