# E/M visit with procedure



## jnieto625 (Apr 7, 2009)

How would you code the following note:

CC: 
Mr. is a 76-year-old male.  This is a follow-up visit.  He presents with lesion/sore.  

HPI: 

Mr. presents with unspecified skin lesion.  There is a solitary skin lesion of concern.  This was first noticed several years.  It is located on the left arm.  He describes this area as raised.  patient having shoulder surgery next week doctor dean preop testing has been completed cardiologist gave clearance 

ROS: 
CONSTITUTIONAL:  Negative for chills, fatigue, fever, and weight change.  
EYES:  Negative for blurred vision, eye pain, and photophobia.  
CARDIOVASCULAR:  Negative for chest pain, pedal edema and jvd.  
RESPIRATORY:  Negative for cough, dyspnea, and hemoptysis.  
GASTROINTESTINAL:  Negative for abdominal pain, heartburn, constipation, diarrhea, and stool changes.  
GENITOURINARY:  Negative for dysuria, hematuria, urinary incontinence and change in urine stream.  
MUSCULOSKELETAL:  Negative for limb pain and myalgias.  
INTEGUMENTARY:  Negative for rash.  
NEUROLOGICAL:  Negative for ataxia, dizziness, fainting, paresthesias and weakness.  
ENDOCRINE:  Negative for hair loss, heat/cold intolerance, polydipsia, and polyphagia.  
ALLERGIC/IMMUNOLOGIC:  Negative for urticaria.  
PSYCHIATRIC:  Negative for crying spells, personality change, sadness and suicidal thoughts.  

Past Medical History / Family History / Social History: 

Past Medical History: 


CURRENT MEDICAL PROVIDERS:
Cardiologist: Dr 
Gastroenterologist: Dr. 
Orthopedist: Dr. 

Health Maintenance:
Colonoscopy: 2008 negative 

Surgical History: 

Arthroscopy: Rt shoulder; 2004; 
Pace Maker 1/2006; 

Family History: 
Father: Died at age 52;  Congestive Heart Failure 
Mother: Died at age 80;  Congestive Heart Failure 
Positive for Type 2 Diabetes ( father ).  

Social History: 
Occupation:
Retired 
Marital Status: Married 
Children: 3 children 
Hobbies/Recreation: he enjoys sports ( golf ); 
Exercise: Frequency is daily.  

Tobacco/Alcohol/Supplements: 
Tobacco: Past history of cigarette smoking, but has quit.  

Alcohol:
Drinks alcohol on a social basis only.  

Current Problems: 
CAD 
Essential hypertension, benign 
High cholesterol 
kidney stones 

Allergies: 
  No Known Drug Allergies. 

Current Medications: 
Aspirin (ASA) 81mg Tablets, Enteric Coated Take 1 tablet(s) by mouth qam 
Coreg 6.25mg Tablet Take 1 tablet(s) by mouth bid 
Cozaar 50mg Tablet Take 1 tablet(s) by mouth daily 
Aleve 220mg Tablet Take 1 tablet(s) by mouth q12h prn for pain 
Lipitor 20mg Tablet 

OBJECTIVE:

Vitals: 

Current: 4/3/2009 10:07:44 AM
Ht: 71 inches;  Wt: 214 lbs;  BMI: 29.85
T: 98 F;  BP: 122/70 mm Hg;  P: 80 bpm;  R: 20 bpm

Exams: 

GENERAL: well developed, well nourished, in no apparent distress 
NECK: Neck is supple with full range of motion; thyroid is normal to palpation; 
RESPIRATORY: normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs; 
CARDIOVASCULAR: normal rate; regular rhythm; no murmurs, rubs, or gallops 
GASTROINTESTINAL: normal bowel sounds; no masses or tenderness; 
GENITOURINARY: 
LYMPHATIC: no enlargement of cervical nodes; 
MUSCULOSKELETAL: grossly normal tone and muscle strength; full, painless range of motion of all major muscle groups and joints 
SKIN: no ulcerations, lesions or rashes 
NEUROLOGIC: 
PSYCHIATRIC: mental status: alert and oriented x 3; 

Procedures: 
Unspecified skin lesion 

Procedure Note: 
Informed consent obtained verbally.  He expresses understanding that a scar may remain after the lesion is removed.  Sterile technique is observed.   
Benign appearing lesion #1 is located on left elbow.   The method of removal is shave removal.   Anesthesia was obtained with 0.5 cc of 1% lidocaine with epinephrine.   Hemostasis is achieved with application of pressure and silver nitrate.   The specimen is sent for pathology review.  

ASSESSMENT: 

239.2	    Unspecified skin lesion 
401.1	    Essential hypertension, benign 

ORDERS: 

Procedures Ordered: 
  11300  Shaving of epidermal or dermal lesion, single lesion, trunk, arm, legs; lesion diameter 0.5 cm or le  

Other Orders: 
  A4550  Surgical trays (x1) 

PLAN: 

 Unspecified skin lesion 

  Orders: 
  11300  Shaving of epidermal or dermal lesion, single lesion, trunk, arm, legs; lesion diameter 0.5 cm or le  
            A4550  Surgical trays (x1) 

 Essential hypertension, benign 

FOLLOW-UP: Schedule a follow-up appointment in 6 weeks..  .  

Patient Recommendations:

For  Essential hypertension, benign: 
Schedule a follow-up visit in 6 weeks


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## LLovett (Apr 7, 2009)

Even though it looks like the doctor did a lot more than is required for the procedure itself, the way the note is documented I would only give credit for the procedure.

I am assuming the follow up was for the HTN but since it is not specified and not mentioned in the HPI at all, the only stated reason for the visit is the lesion. 

I also don't like the fact that when using templated EMR you end up with things like "SKIN: no ulcerations, lesions or rashes" when he came in for a lesion. 

Just my opinion,

Laura, CPC


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## cdcpc (Apr 7, 2009)

*I agree*

I also agree with Laura that the lesion removal procedure should be the only thing charged.  The documentation is very detailed, but there is no significant seperately identifiable problem dealt with, so it would not be appropriate to charge an office visit.

Laura--I also have that same pet peeve about EMR's....sometimes it makes it seem like our physicians are contradicting themselves!


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## jnieto625 (Apr 8, 2009)

This is what I have been trying to explain to my physicians 

Thanks


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## cdcpc (Apr 8, 2009)

jdelgado625 said:


> This is what I have been trying to explain to my physicians
> 
> Thanks



I find when I'm educating my physicians, I have to package the information in a way that they'll appreciate.  If the physician is worried about loosing revenue by not charging the office visit, I try to tell them that they can save time by just documenting what's necessary (ie the procedure only) for this patient and they can use the extra time to squeeze in another patient.


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## jnieto625 (Apr 10, 2009)

I suggested they take one half day a week to do small office procedures like cryosurgery, where they can schedule a patient every 10 minutes or so.  I am hoping this helps.


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