Wiki HPI & Exam help

JS81coder

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Would this HPI have three elements?

Mod Fac - currently on immunosuppressive medication
Context - tx for warts with liquid nitrogen
Loc - skin

The 52 yr old patient had a renal transplant Jan 2013 is currently on immunosuppressive medication.
The patient has been treated in the past for genital warts with liquid nitrogen - last treatment May 2012.
The patient presents today for a skin cancer check in view of his history of renal transplantation.

Organ transplant patients are at greater risk (65X) for developing skin cancer especially SSC. They tend to be more aggressive and may spread. Risk factors include ultraviolet exposure, immunosuppression and HPV/wart infection. Management include prevention (sun protection), early detection (regular skin exam) and appropriate treatment (liquid nitrogen, electrocautery, excision, topical creams, oral retinoids and reducing levels all immunosuppressive medications.)

Would the provider have an EPF exam under the 97 guidelines?

Exam:
In addition to General, the provider has additional exam: A full body skin exam performed. Except as noted, the remainder of the skin exam of the scalp, head (including the face), neck, chest (including axillae), abdomen, back and genitalia (including buttocks and groin), arm and legs is clear of any atypical lesions.
The patient has a number of minimally raised, hyperpigmented plaques on the shaft of the penis consistent with condylomata acuminata.

I am new to auditing derm and would apperciate any feedback.
 
EPF history

The reason for the visit is:Skin cancer check

HPI - SKIN (location), hx of renal transplant (context), treatment w/ liquid nitrogen (mod factor)

ROS: GU (genital warts), ALLERGIC/IMMUNOLOGIC (on immunosuppresive drugs)

PMFSH: Past medical (renal transplant)
No family history in documentation provided
No social history in documentation provided

This means you have an EPF History

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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