Here are my charges - Does the HPI meet the requirements to bill the e/m? A couple of payors are now auditing for the same dx being used with the e/m so worried the HPI isn't detailed enough.
99203-25 - Dx C44.622 and L57.0
17261-59 - Dx C44.622
17000 x 1 - Dx L57.0
17003 x 9 - Dx L57.0
Chief Complaint: New lesion
HPI: This is a 93 year old male who comes in for a chief complaint of new lesion on the right superior helix. The new lesion is red and mild in severity. The new lesion has been present for 3 months.
Medications - See List
Allergies - NKA
ROS - A full review of systems was performed and negative
Medical Hx - DM, HTN, Hypothyroidims
Social Hx - Unspecified
Exam: An exam was performed including the scalp (including hair inspections), Head (including face), inspection of conjunctivae and lids, neck, chest, abdomen, back, right upper extremity, left upper extremity, right lower extremity, and left lower extremity.
Findings in the above examined areas were normal with the exception of the followng:
-AK of the left distal dorsal forearm, right distal dorsal forearm, right proximal dorsal forearm, right proximal posterior upper arm, right inferior central malar cheek, right central buccal cheek, right superior helix, left superior helix, and left central forehead.
-Squamous cell carcinoma on the right dorsal wrist
Hypertrophic erythematous papules with hyperkeratoic scale
distrubuted on the arm, face, and ear.
I counseled the patient regarding the following:
Skin Care: Sun protective clothing and sunblock can prevent the formation of AK. AKs can resolve with cryotherapy, photodynamic therapy, imiquimod, topical 5-FU.
Expectations: AK are precancerous proliferations that occur within sun damaged skin. If untreated, a small subset of AKs can develop into Squamous Cell Carcinoms.
Contact office is: AKs fail to resolve despite treatment, or if you delvelop a side effect from therapy, such as unbearable crusting, scabbing, redness and tenderness.
Plan: Liquid Nitrogen Multi
A total of 10 lesions were treated with Liquid nitro for 1 free-thaw cycle, located on the arm, face, adn ear. The patient's consent was obtained including and not limited to risks.
2. Squamous Cell Carcinoma
Erythematous tender nodule with hyperkeratoric scale locatedo nt he right dorsal wrist.
I counseled patient regarding the following:
Instructions: Squamous Cell Carcinoma can be removed via surgical excision, mohs surgery or XRT. Low risk or superficially invasive SCCs on the trunk and extremities can be removed via ED&C although recurrences are higher than with excision.
Expectations: SCC are a form of skin cancer. Sun exposure, sunburns, radiation exposure, HPN exposure, immunosuppression are all risk factors.
Contact office if: patient develops any new lesions that fail to heal, ulcerate or bleed.
Plan: Cryosurgical destruction
A 0.9 cm SCC on the right dorsal wrist was treated with cryosurgical destruction. the surgical site was antiseptically prepared. The tumor was cryosurgically destroyed with LN with 2 freex thaw cycles for 3 minutes. The wound was cleaned and a dressing was applied. Patient received detailed post op instructions.