I'm needing some other opinions on two procedures done, a couple of skin tags and a lesion. They were two different dates of service as well.
Can anyone tell me what they think they should be coded based on the documentation provided pretty please??? And also the DX's? I put in red what my opinion is...
DOS 01/18/2013
It is a pleasure to meet this newborn child. He is approximately 2 weeks of age and it has been noted that he has some right-sided skin tags as well as a larger preauricular lesion on the left. His hearing screening was normal. He was born full term. No other perinatal concerns. He has been feeding well. No issues with weight gain. No other active issues present today.
Ear:
Both external ears, canals and the tympanic membranes appear normal. No evidence of effusion. Normal landmarks seen. 2 right sided preauricular tags.One large left side auricular duplicate
Office Procedure
Procedure: excision of skin tag 2 right sided preauricular lesions removed with irris scissor
Assessment and Plan
ICD: Other Congenital Anomaly Of Ear (744.29)
ICD: Benign Neoplasm Of Scalp And Skin Of Neck (216.4)
With his mother's permission we proceeded with the removal of the small skin tags that were identified on the right side. A small iris scissor was used to this purpose with little injury and no significant discomfort. The lesion on the left is more prominent and most likely has center or core of cartilage. It is an auricular duplicate and would require more extensive dissection for its removal. I would like to remove it soon as we would be able to do so here in the office with some preparation. We have described the need for its excision and the family would like to proceed. We will schedule him for this in office procedure. The skin tags were removed without any difficulty today.
Follow up: 1 Week excision of left auricular duplicate 11200 with 744.29 (someone suggested 757.39)
DOS 01/25/2013
Office Procedure
Procedure: excision of auricular duplicate left ear
After signing a consent we proceeded with the excision of the lesion today. He was present in the left preauricular space. Anterior to the tragus we injected approximately 1/2 cc of lidocaine with epinephrine. The wound was then prepped and draped. Once prepared we made our incisions in an elliptical fashion surrounding the lesion. It was removed.
Once removed hemostasis was achieved with silver nitrate. The wound was then closed with a simple suture. Mastisol and a Steri-Strip was then applied. He tolerated the procedure very well.
Assessment and Plan
ICD: Other Congenital Anomaly Of Ear (744.29)
ICD: Benign Neoplasm Of Scalp And Skin Of Neck (216.4)
11440-58 with 216.4
Can anyone tell me what they think they should be coded based on the documentation provided pretty please??? And also the DX's? I put in red what my opinion is...
DOS 01/18/2013
It is a pleasure to meet this newborn child. He is approximately 2 weeks of age and it has been noted that he has some right-sided skin tags as well as a larger preauricular lesion on the left. His hearing screening was normal. He was born full term. No other perinatal concerns. He has been feeding well. No issues with weight gain. No other active issues present today.
Ear:
Both external ears, canals and the tympanic membranes appear normal. No evidence of effusion. Normal landmarks seen. 2 right sided preauricular tags.One large left side auricular duplicate
Office Procedure
Procedure: excision of skin tag 2 right sided preauricular lesions removed with irris scissor
Assessment and Plan
ICD: Other Congenital Anomaly Of Ear (744.29)
ICD: Benign Neoplasm Of Scalp And Skin Of Neck (216.4)
With his mother's permission we proceeded with the removal of the small skin tags that were identified on the right side. A small iris scissor was used to this purpose with little injury and no significant discomfort. The lesion on the left is more prominent and most likely has center or core of cartilage. It is an auricular duplicate and would require more extensive dissection for its removal. I would like to remove it soon as we would be able to do so here in the office with some preparation. We have described the need for its excision and the family would like to proceed. We will schedule him for this in office procedure. The skin tags were removed without any difficulty today.
Follow up: 1 Week excision of left auricular duplicate 11200 with 744.29 (someone suggested 757.39)
DOS 01/25/2013
Office Procedure
Procedure: excision of auricular duplicate left ear
After signing a consent we proceeded with the excision of the lesion today. He was present in the left preauricular space. Anterior to the tragus we injected approximately 1/2 cc of lidocaine with epinephrine. The wound was then prepped and draped. Once prepared we made our incisions in an elliptical fashion surrounding the lesion. It was removed.
Once removed hemostasis was achieved with silver nitrate. The wound was then closed with a simple suture. Mastisol and a Steri-Strip was then applied. He tolerated the procedure very well.
Assessment and Plan
ICD: Other Congenital Anomaly Of Ear (744.29)
ICD: Benign Neoplasm Of Scalp And Skin Of Neck (216.4)
11440-58 with 216.4
