Is the note below considered Expanded problem focus under 1995 exam guidelines?
I'd just like others opinion because I would count the Head as 1 point and the constitutional and psychiatric note as 2 points giving me a total of 3 points and expanded problem focus under 1995 exam guidelines (2-7 body areas and/or organ systems)
Also would you bill the injection with the new patient E/M (99202-25 & 11900)?
Thank you.
Chief Complaint and/or History of Present Illness
Complaint(s):
1. Hair loss on left and occipital scalp
Symptom: local patch
Duration: 1 months
Severity: worsening
Timing: constant
Context: pt tried otc biotin from gnc but doesent seem to help. denies family h/o lupus, dm, anemia and hair loss
Modifying Factors: none
Complete ROS and HISTORY taken
Physical Exam, Diagnosis, Medical Decision Making and Plan of Care
Constitutional, Neurological and Psychiatric Notes:
? Patient is a 31 year old male who appears to be well developed and well nourished with good attention to
hygiene. Psychiatric Note: The patient appears to be oriented by time, place and person.
Skin Type:
? Patient has skin type IV (Beige with a Brown Tint).
Exam Type:
? Eyelid, lip, face, neck, ear.
Exam:
1. Alopecia, areata
2cm x 3cm alopecic patch located on occipital scalp and left
Medical Decision Making: Alopecia, areata , ilk
POC: Recommendation is Explained Alopecia Areata. AA occurs more frequently in people who have
affected family members, suggesting heredity may be a factor. In addition, it is slightly more likely to occur
in people who have relatives with autoimmune diseases. The condition is thought to be a systemic
autoimmune disorder in which the body attacks its own anagen hair follicles and suppresses or stops hair
growth. 0.6cc ILK 10mg (straight) injected. Lab slip given for bio ref check Vit D and TSH. Trial of OTC
rogaine for men - recommend foam version for ease of application. Explained new hair growth may be
fine and white or salt + pepper. Do not pluck or pull out., Intralesional Kenalog Injections - Area cleaned
with alcohol wipe - Kenalog 10mg/cc injected into each lesion - Patient tolerated the procedure well -
Patient may return in 4 weeks for re-treatment
I'd just like others opinion because I would count the Head as 1 point and the constitutional and psychiatric note as 2 points giving me a total of 3 points and expanded problem focus under 1995 exam guidelines (2-7 body areas and/or organ systems)
Also would you bill the injection with the new patient E/M (99202-25 & 11900)?
Thank you.
Chief Complaint and/or History of Present Illness
Complaint(s):
1. Hair loss on left and occipital scalp
Symptom: local patch
Duration: 1 months
Severity: worsening
Timing: constant
Context: pt tried otc biotin from gnc but doesent seem to help. denies family h/o lupus, dm, anemia and hair loss
Modifying Factors: none
Complete ROS and HISTORY taken
Physical Exam, Diagnosis, Medical Decision Making and Plan of Care
Constitutional, Neurological and Psychiatric Notes:
? Patient is a 31 year old male who appears to be well developed and well nourished with good attention to
hygiene. Psychiatric Note: The patient appears to be oriented by time, place and person.
Skin Type:
? Patient has skin type IV (Beige with a Brown Tint).
Exam Type:
? Eyelid, lip, face, neck, ear.
Exam:
1. Alopecia, areata
2cm x 3cm alopecic patch located on occipital scalp and left
Medical Decision Making: Alopecia, areata , ilk
POC: Recommendation is Explained Alopecia Areata. AA occurs more frequently in people who have
affected family members, suggesting heredity may be a factor. In addition, it is slightly more likely to occur
in people who have relatives with autoimmune diseases. The condition is thought to be a systemic
autoimmune disorder in which the body attacks its own anagen hair follicles and suppresses or stops hair
growth. 0.6cc ILK 10mg (straight) injected. Lab slip given for bio ref check Vit D and TSH. Trial of OTC
rogaine for men - recommend foam version for ease of application. Explained new hair growth may be
fine and white or salt + pepper. Do not pluck or pull out., Intralesional Kenalog Injections - Area cleaned
with alcohol wipe - Kenalog 10mg/cc injected into each lesion - Patient tolerated the procedure well -
Patient may return in 4 weeks for re-treatment
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