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Problem-Focused Exam question?

Amy Posted Mon 03rd of December, 2012 20:22:23 PM

I am now taking a test for the same company after General Surgery, Opthamology. THis test is for E/M and ICD-9 coding.

This patient has a exam that only gets into the skin, eyes, and forehead, rest states: ROS otherwise well as they are still mentioned! The Past, Social, Family Hx are mentioned as well. I coded CPT-99243? Is this correct?
For the DX codes, says likely basal cell carcinoma of the forehead? Hematosis was achieved. If it says likely can you use it in the OV for a dx? I forget? THe beginning of the report states lesion on the forehead, he has a hx of lesion on the right forehead in the past? How about Actinic Keratosis of the left ear?

THis is what I coded for the dx's codes 1. 195.0 for lesion of the forehead 2. 385.30 for actinic keratosis of the left ear 3. 195.4 hx of squamous cell carcinoma of arm? Are these correct?


Amy Bedford-CPC

SuperCoder Answered Tue 04th of December, 2012 19:25:08 PM

Hi Amy,

We can't give an E/M code without knowing all the details. We would need the actual details of the documentation, including HPI, ROS, PMFSH, exam details, and dx/assessment/plan to determine MDM. We can't tell the code without all the elements. Please provide us the complete picture.

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