Wiki Repost procedure note help!

[maine4me]

I need help with this note for removal of lesion. Dr. gave 11100 and 11101, no modifier. I think it should be 11400 - 53 and 11406. So who is right?


Assessment and Plan
Ambulatory Assessment/Plan:
Assessment/Plan:
759.6 Epidermal nevus

214.9 Lipoma

Additional Plan Details:
759.6 Epidermal nevus-cyst left midback

214.9 Lipoma

sterile prep to both lesions
anest c xylo c epi
back cyst removed in toto after ellipse cut
defect clsed c 2 3-O sutures

left flank lesion incised c scalpel
removed top fatty and CT
lesion went deep
closed c 2 3-O sutures
if desires removal will send to surgery

remove sutures 7 days
wound care explained
call c problems

HPI
HPI
Nursing Chief Complaint: mole removal

Physician: here for lesion removal x 2
Vitals:
Height 70 in / 177.80 cm
Weight 172 lbs / 78.017893 kg
BSA 1.97 m2
BMI 24.7 kg/m2
Temperature 98 F / 36.66 C - Oral
Pulse 68
Blood Pressure 100/80 Sitting, Left Arm
Personal Medical History
Personal medical history: Hx of: High cholesterol, Depression,
No hx of: Coronary Artery Disease

Social History
Social history:
Marital Status: Married
Occupation: owner-pizza parlor

EXAM
*****
*****
left lower abd/flank c fatty feeling cystic lesion
round, nontender, no skin chnages

left midback-8 mm oval lesion, cystic feel
nontender

Constitutional
General Appearance: NAD

 

[FTessaBartels]

Repeat post

I answered in the other post.

F Tessa Bartels, CPC, CEMC

 

[mitchellde]

The note lacks substance for coding a procedure in my opinion. You know from the end that there is an 8mm oval lesion but you really do not know if this was the one removed. From the note you have no idea if this was excised or shaved and how large the incision was there is no mention of margins. There is no reference in the note to the pathology of the lesion removed. As to the second procedure I cannot tell if something was removed and submitted for path or if it was just looked at and closed. The note as it stands looks like an E&M, I see that something was done but not to an extent that it can be coded.