Bernadette10
Guru
Is this enough documentation to bill 99213-25 and 11055, or would it be 11055 only? I don't see any consideration of options and then a decision to do the callus trimming, but there was a separate exam, so I was thinking 99213 could be billed.
HPI
This is a 71 year old male here for followup.
Allergies: Hydroxyzine.
ROS:
HEENT: Negative
Respiratory: Negative
Musculoskeletal: Negative
Neurological: Negative
Exam:
General: Alert and oriented to person, place and time.
Vascular:
DP: Palpable Left 1, Right 1
PT: Pedal pulses palpable Left 1, Right 1
Pedal hair present bilaterally.
No edema, ecchymosis or erythema.
Skin temperature warm to cool proximal to distal bilaterally.
No varicosities/spider veins bilaterally.
Neurological:
Sensation intact to superficial and light touch to all nerve distributions of foot.
Sensation intact to 10 g monofilament bilaterally.
Deep tendon reflexes 2+ for patellar and achilles bilaterally.
No muscle atrophy noted bilaterally.
Skin:
Callus of plantar 4th digit left foot.
Open wounds absent.
No signs of infection.
Assessment/Plan:
Callus left foot. Trimmed with 11 blade.
HPI
This is a 71 year old male here for followup.
Allergies: Hydroxyzine.
ROS:
HEENT: Negative
Respiratory: Negative
Musculoskeletal: Negative
Neurological: Negative
Exam:
General: Alert and oriented to person, place and time.
Vascular:
DP: Palpable Left 1, Right 1
PT: Pedal pulses palpable Left 1, Right 1
Pedal hair present bilaterally.
No edema, ecchymosis or erythema.
Skin temperature warm to cool proximal to distal bilaterally.
No varicosities/spider veins bilaterally.
Neurological:
Sensation intact to superficial and light touch to all nerve distributions of foot.
Sensation intact to 10 g monofilament bilaterally.
Deep tendon reflexes 2+ for patellar and achilles bilaterally.
No muscle atrophy noted bilaterally.
Skin:
Callus of plantar 4th digit left foot.
Open wounds absent.
No signs of infection.
Assessment/Plan:
Callus left foot. Trimmed with 11 blade.