# Help with Op notes!!!!!!



## maine4me (Oct 6, 2011)

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


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## FTessaBartels (Oct 7, 2011)

*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


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## mitchellde (Oct 7, 2011)

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?


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## maine4me (Oct 11, 2011)

*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


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## FTessaBartels (Oct 14, 2011)

*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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