# ob/gyn code a round round 1 note 4



## allyson815@gmail.com (Aug 5, 2012)

Est Patient here for Preop appt

Subjective
CC: Patient presents for preoperative visit. Laser surgery scheduled for 11/06/xx  and treatment of perineal warts.

HPI:
ROS:
Const: Denies weight gain and unexplained weight loss. General health stated as good.
Resp: Denies chronic cough, coughing up blood, SOB and wheezing.
Gl: Denies constipation and diarrhea.
GU: Genital: denies dysmenorrhea and menorrhagia. Urinary: denies frequency and urgency. 
Breast: Denies discharge, masses and pain.
Endocrine: Denies hot flashes.
Allergy/Immuno: Denies allergic/immunologic symptoms.


Current Meds: Invega 9 mg, Lexapro 20 mg, Advair Diskus 250/50, Nasonex 50 mcg/act, Albuterol 90 mcg/act, Aerochamber Plus, Xanax XR 1 mg, Topamax 100 mg, Glucophage 1000 mg, Abilify 10mg

Allergies:   Prozac, Bee Stings, Tape, Ativan, Aleve, Ibuprofen - Rash, Toradol - Itching, DarvocetN-100 - N-V, Seroquel


PMH:
Medical Problems: IDDM, Genital Herpes, Multiple Personality Disorder, Severe Depression

Surgeries: Dilation & Curettage, Tonsillectomy, Laser To Cervix, Herpes- Genital
OB/Gyn Hx: Gravidity: (2) Parity: Living (2)
Reviewed, no changes.

FH:
Father: Deceased due to Schitzophrenia.
Mother: BI-POLAR
Reviewed, no changes.

SH:
Marital: divorced. Lives With: Mother. Smoke Free: Home is not smoke-free. Work Status: Not 
Currently Working. Advance Directive: Negative For Living Will
Personal Habits: Cigarette Use: current cigarette smoker. Current Cigarette Smoker 1 Pack 
Daily. Alcohol: Denies alcohol use. Drug Use: Denies Drug Use. 
Reviewed, no changes.

Objective
Wt: 183 Wt Prior: 183 as of 10/23/xx Wt Dif: 0 BP: 115/72 Ht 66" 5'6" LMP: 10/23/xx

Exam:
Const: Appears the stated age, healthy and well groomed. Appears moderately overweight. Alert and oriented. 
Resp: Auscultate good airflow.
CV: Rate is within normal range. No heart murmur appreciated.
Abdomen: Abdomen is soft, nontender, and nondstended without guarding, rigidity or rebound tenderness. 
GU: Exam deferred until procedure .
Lymph: No palpable lymphadenopathy in the subclavicular or suprclavicular region(s).
Musculo: Normal muscle tone. 
Skin: Skin is warm and dry.

Assessment & Plan #1:  Viral Warts Unspec:

Comments : Discussed laser procedure including risks. Discussed sitz baths, vicodin for pain and silvedene cream for after procedure. Patients questions answered. Instructed to stop glucophage 48 hours before procedure.

I have the cpt and icd 9 codes I thought were correct but it keeps saying I need more.
Please help


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## huntersmum (Aug 9, 2012)

What do you have so far?


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## allyson815@gmail.com (Aug 12, 2012)

99213, 078.10


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## Leandra (Aug 13, 2012)

How about adding the pre-op diagnosis code - V72.8_ - we use these a lot when pt's come in for pre-op exams.


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## allyson815@gmail.com (Aug 13, 2012)

I tried V72.8 and it said it was incorrect


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## huntersmum (Aug 15, 2012)

I would have added V72.83 to that - but that didn't work?


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