How would this office visit be coded? I'm thinking you would only code the procedures & not the E&M, and not sure what diagnosis codes to use, because of the descriptions of the diagnosis. I'm new at general surgery, so any advice would be greatly appreciated.
New Patient
CHIEF COMPLAINT:
Multiple skin lesions on scalp, face,back and abdomen.
HISTORY OF PRESENT ILLNESS:
35 y/o otherwise healthy male has been complaining of recurrent skin lesions on scalp and face back and abdominal wall. He has no pain..
he had one on scalp removed once and has recurred.
ALLERGIES:
Allergies Reviewed
Bactrim
Ceclor
Keflex
Augmentin
Amoxicillin
Allergy list reviewed. updated
CURRENT MEDICATIONS:
Medications List Reviewed
PARoxetine HCl Oral Tablet 20 MG
Medication list reviewed. updated
PAST MEDICAL HISTORY:
Other past medical history includes Anxiety
SURGICAL HISTORY:
Tonsillectomy
Appendectomy
Previous surgery includes abd surgery(abd muscle when a baby)
SOCIAL HISTORY:
Smoking Status: Never smoker
No counseling on tobacco cessation
Rx therapy for tobacco cessation
Did not discuss Smoking/Tobacco Use Cessation Strategies
Alcohol use: Occasional
REVIEW OF SYSTEMS:
General:
No constitutional symptoms.
Neck:
no neck symptoms.
Eyes:
no eye symptoms.
Cardiovascular:
no cardiovascular symptoms.
Respiratory:
no respiratory symptoms.
Gastrointestinal:
No GI symptoms.
Genitourinary:
no GU symptoms.
Endocrine:
no endocrine symptoms.
Musculoskeletal:
no musculoskeletal symptoms.
Neurologic
no neurologic symptoms.
Skin:
Multiple lesions as above..
VITAL SIGNS: are documented
PHYSICAL EXAMINATION:
General:
alert, oriented to time, place and person, well nourished, in no acute distress.
Head:
On right scalp area there is a 5-6 mm raised verruca lesion with hair on it. no redness.
On right face cheek area there are 2 small skin pappilomas.
Neck:
2 separate small verruca lesions.
Lymphatics:
Negative lymph node exam.
Respiratory:
Negative lung exam.
Cardiovascular:
Negative heart exam.
Back:
Large skin pappiloma lesion 7-8 mm in size.
Abdomen/Gastrointestinal:
2 small verruca lesions.
Musculoskeletal:
Negative musculoskeletal exam.
ASSESSMENT:
Multiple verruca lesions scalp abdomen.
Multiple skin pappiloma face and back.
PLAN:
1. Excision of large verruca lesion on scalp.
2. Electrodessication of multiple skin pappiloma and verruca lesions face. neck abdomen and back.
Wound care was given.
PROCEDURE NOTE:
Excision of large recurrent verruca lesion scalp 6 mm in size.
Consent was done.
Area on scalp was prepped with betadine and draped.1% lidocaine was injected.
using a # 15 scalpel ellipticle incision was made deep and wide and entire lesion was excised. Wound was closed with 3-0 vicryl suture. Oinrment was applied, No blood loss.
Electrodessication of multiple skin lesions was done with lidocaine injection and complete dessication of lesions were done.
New Patient
CHIEF COMPLAINT:
Multiple skin lesions on scalp, face,back and abdomen.
HISTORY OF PRESENT ILLNESS:
35 y/o otherwise healthy male has been complaining of recurrent skin lesions on scalp and face back and abdominal wall. He has no pain..
he had one on scalp removed once and has recurred.
ALLERGIES:
Allergies Reviewed
Bactrim
Ceclor
Keflex
Augmentin
Amoxicillin
Allergy list reviewed. updated
CURRENT MEDICATIONS:
Medications List Reviewed
PARoxetine HCl Oral Tablet 20 MG
Medication list reviewed. updated
PAST MEDICAL HISTORY:
Other past medical history includes Anxiety
SURGICAL HISTORY:
Tonsillectomy
Appendectomy
Previous surgery includes abd surgery(abd muscle when a baby)
SOCIAL HISTORY:
Smoking Status: Never smoker
No counseling on tobacco cessation
Rx therapy for tobacco cessation
Did not discuss Smoking/Tobacco Use Cessation Strategies
Alcohol use: Occasional
REVIEW OF SYSTEMS:
General:
No constitutional symptoms.
Neck:
no neck symptoms.
Eyes:
no eye symptoms.
Cardiovascular:
no cardiovascular symptoms.
Respiratory:
no respiratory symptoms.
Gastrointestinal:
No GI symptoms.
Genitourinary:
no GU symptoms.
Endocrine:
no endocrine symptoms.
Musculoskeletal:
no musculoskeletal symptoms.
Neurologic
no neurologic symptoms.
Skin:
Multiple lesions as above..
VITAL SIGNS: are documented
PHYSICAL EXAMINATION:
General:
alert, oriented to time, place and person, well nourished, in no acute distress.
Head:
On right scalp area there is a 5-6 mm raised verruca lesion with hair on it. no redness.
On right face cheek area there are 2 small skin pappilomas.
Neck:
2 separate small verruca lesions.
Lymphatics:
Negative lymph node exam.
Respiratory:
Negative lung exam.
Cardiovascular:
Negative heart exam.
Back:
Large skin pappiloma lesion 7-8 mm in size.
Abdomen/Gastrointestinal:
2 small verruca lesions.
Musculoskeletal:
Negative musculoskeletal exam.
ASSESSMENT:
Multiple verruca lesions scalp abdomen.
Multiple skin pappiloma face and back.
PLAN:
1. Excision of large verruca lesion on scalp.
2. Electrodessication of multiple skin pappiloma and verruca lesions face. neck abdomen and back.
Wound care was given.
PROCEDURE NOTE:
Excision of large recurrent verruca lesion scalp 6 mm in size.
Consent was done.
Area on scalp was prepped with betadine and draped.1% lidocaine was injected.
using a # 15 scalpel ellipticle incision was made deep and wide and entire lesion was excised. Wound was closed with 3-0 vicryl suture. Oinrment was applied, No blood loss.
Electrodessication of multiple skin lesions was done with lidocaine injection and complete dessication of lesions were done.