Podiatry is not my specialty, but I've been tasked with processing claims for submission, AND auditing the provider's documentation and coding. I have removed the PFSH (it was copy and pasted so is inadmissible anyway), otherwise the note is exactly how the provider wrote it.
How would you code/audit this visit?
Chief Complaints:
1. Pt. presents for 6 wk. f/u care for thick ingrown nails L foot. Pt. has been applying topical medication to affected nails twice a day..
Physical Examination:
Pt. has a thick ingrown Hallux nails. Pt. is applying Formula-3 medication to affected nails L Hallux.
Assessment:
1. Ingrowing nail - 703.0 (Primary)
2. Hypertrophy of nail - 703.8
3. Foot pain - 729.5
4. Dermatophytosis of foot - 110.4
5. Atherosclerosis of the extremities, unspecified - 440.20
Plan:
1. Ingrowing nail
Notes: Excision on nails border L Hallux. Pt. to continue apply Formula-3 to Hallux BID.
Follow Up: 6 Weeks, 2 Months
Thanks,
Arrana
How would you code/audit this visit?
Chief Complaints:
1. Pt. presents for 6 wk. f/u care for thick ingrown nails L foot. Pt. has been applying topical medication to affected nails twice a day..
Physical Examination:
Pt. has a thick ingrown Hallux nails. Pt. is applying Formula-3 medication to affected nails L Hallux.
Assessment:
1. Ingrowing nail - 703.0 (Primary)
2. Hypertrophy of nail - 703.8
3. Foot pain - 729.5
4. Dermatophytosis of foot - 110.4
5. Atherosclerosis of the extremities, unspecified - 440.20
Plan:
1. Ingrowing nail
Notes: Excision on nails border L Hallux. Pt. to continue apply Formula-3 to Hallux BID.
Follow Up: 6 Weeks, 2 Months
Thanks,
Arrana