sjsantjer
Networker
Would you bill the E&M? Dr wants to bill:
99213-25
11100
Established Patient
CC: Scalp Lesion
Lesion on back scalp, present a few months, no itching, not bleeding, not painful, not really growing.
KNA
Meds: …… listed.
ROS: Hx of skin cancer. No SOB, No problems with healing. Does not develop keloids after surgery. Does not bleed easily.
Social Hx- non smoker
Exam: Pt is frail and elderly, oriented x 3, affect appropriate, capable of following directions. Scalp/Hair 4cm firm sub q nodule. Head/face/nose/ears, conj/eyelids clear. Neck questionable small node.
Lipoma-Tried to excise without success. Punch bx taken from yellow sub q nodule. Alcohol prep, 1% buffered Xylo w/ Epi, 3mm punch……. Path report to be called. Further Tx based on report. Return 1 week for suture removal.
Pathology- Involved by a low-grade B cell lineage malignant lymphoma. Referred to cancer Dr.
Thank you!
99213-25
11100
Established Patient
CC: Scalp Lesion
Lesion on back scalp, present a few months, no itching, not bleeding, not painful, not really growing.
KNA
Meds: …… listed.
ROS: Hx of skin cancer. No SOB, No problems with healing. Does not develop keloids after surgery. Does not bleed easily.
Social Hx- non smoker
Exam: Pt is frail and elderly, oriented x 3, affect appropriate, capable of following directions. Scalp/Hair 4cm firm sub q nodule. Head/face/nose/ears, conj/eyelids clear. Neck questionable small node.
Lipoma-Tried to excise without success. Punch bx taken from yellow sub q nodule. Alcohol prep, 1% buffered Xylo w/ Epi, 3mm punch……. Path report to be called. Further Tx based on report. Return 1 week for suture removal.
Pathology- Involved by a low-grade B cell lineage malignant lymphoma. Referred to cancer Dr.
Thank you!
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