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Help with Op notes!!!!!!

  1. Default Help with Op notes!!!!!!
    Medical Coding Books
    I need help with this note for removal of lesion. Dr. gave 11100 and 11101, no modifier. I think it should be 11400 - 53 and 11406. So who is right?

    Assessment and Plan
    Ambulatory Assessment/Plan:
    Assessment/Plan:
    706.2 Cyst of skin

    789.07 Generalized abdominal pain

    Additional Plan Details:
    706.2 Cyst of skin
    rtc for cyst removal x 2

    789.07 Generalized abdominal pain
    likely muscular
    rec 2 weeks rest and prn advil
    call if worsens

    HPI
    HPI
    Nursing Chief Complaint: abdominal pain and bumps on his back

    Physician: suprapubic pain for few weeks
    plays soccer but no trauma recalled
    pain c movement
    no relief c bm, food
    no bulge or bruising seen

    also has few bumps he would like checked
    slowly growing
    no sx from them
    Vitals:
    Height 70 in / 177.80 cm
    Weight 172 lbs / 78.017893 kg
    BSA 1.97 m2
    BMI 24.7 kg/m2
    Temperature 98.3 F / 36.83 C - Oral
    Pulse 64
    Blood Pressure 90/60 Sitting, Left Arm
    Personal Medical History
    Personal medical history: Hx of: High cholesterol, Depression,
    No hx of: Coronary Artery Disease

    Social History
    Social history:
    Marital Status: Married
    Occupation: owner-pizza parlor

    EXAM
    *****
    *****
    skin-flank c 2 cystic subQ masses
    yellow appearance
    nontender. mobile

    Constitutional
    General Appearance: NAD

    Respiratory
    Respiratory effort: Normal
    Auscultation: Bilateral: Normal

    Cardiovascular
    Rhythm: Regular
    Heart sounds: Normal: S1, S2

    Gastrointestinal
    Abdomen description: Normal
    Bowel sounds: ALL: Normal
    Abdominal palpation:
    Abdomen: Nontender, Soft
    Organomegaly/mass:
    Organomegaly: None
    Hernia:
    Location: None

    Lymphatic
    Inguinal lymph nodes:
    Enlarged nodes: None

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default There is no documentation of ANY excision
    The documentation you show is for an E/M visit. There is no documentation of any excision that I can see.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Location
    Columbia, MO
    Posts
    12,531
    Default
    I agree with Tessa there is no documentation of any kind of a procedure. At the top where it says "rtc cyst removal X 2" is insufficient if this is what you are going by for a procedure discontinued or otherwise. Please show where you are getting the support for the codes you chose, "11400 - 53 and 11406" Or is there more to the note that failed to post?

    Debra A. Mitchell, MSPH, CPC-H

  4. Default Sorry, originally posted incorrect note
    Assessment and Plan
    Ambulatory Assessment/Plan:
    Assessment/Plan:
    759.6 Epidermal nevus

    214.9 Lipoma

    Additional Plan Details:
    759.6 Epidermal nevus-cyst left midback

    214.9 Lipoma

    sterile prep to both lesions
    anest c xylo c epi
    back cyst removed in toto after ellipse cut
    defect clsed c 2 3-O sutures

    left flank lesion incised c scalpel
    removed top fatty and CT
    lesion went deep
    closed c 2 3-O sutures
    if desires removal will send to surgery

    remove sutures 7 days
    wound care explained
    call c problems

    HPI
    HPI
    Nursing Chief Complaint: mole removal

    Physician: here for lesion removal x 2
    Vitals:
    Height 70 in / 177.80 cm
    Weight 172 lbs / 78.017893 kg
    BSA 1.97 m2
    BMI 24.7 kg/m2
    Temperature 98 F / 36.66 C - Oral
    Pulse 68
    Blood Pressure 100/80 Sitting, Left Arm
    Personal Medical History
    Personal medical history: Hx of: High cholesterol, Depression,
    No hx of: Coronary Artery Disease

    Social History
    Social history:
    Marital Status: Married
    Occupation: owner-pizza parlor

    EXAM
    *****
    *****
    left lower abd/flank c fatty feeling cystic lesion
    round, nontender, no skin chnages

    left midback-8 mm oval lesion, cystic feel
    nontender

    Constitutional
    General Appearance: NAD

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default Terrible documentation
    I think this is terrible documentation of a procedure. First he has simply used an E/M template, and pasted in the info from an earlier note. Doesn't really matter, as you can't bill an E/M with these procedure in any case, but it raises a red flag for any auditor looking at the documentation.

    He gives no dimensions of the lesions, which is a requirement for coding, though I will admit that since he used only 2 sutures for each wound, the smallest diameter is probably accurate.

    Each lesion is coded separately. You will need a -59 modifier on the second lesion code.

    Lipomas are usually coded from the musculoskeletal section as they are beneath the dermis and into the musculature (which he apparently discovered on making his incision).

    I would use the -53 modifier in coding for the lipoma, as he discontinued the procedure on discovering that the lesion was imbedded deeply.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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