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AAPC - Chapter 19 Practical Applications latest update complete
AAPC - Chapter 19 Practical Applications latest update complete
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AAPC - Chapter 19 Practical Applications latest update 2022 -2023 complete CASE 1 Mark is a 45 years -old male and is here as a new patient (New patient) to have several lipomas removed.(Chief complaint) He has had these for many years.(HPI: Duration) He has had about 12 removed.(ROS: Integumentary) They get bigger slowly over time. (HPI: Severity) Some of them are tender to touch. (HPI: Quality) They get irritated when he is handling people as a firefighter. (HPI: Modifying factors) PAST MEDICAL HISTORY: None. ALLERGIES: None. MEDICATIONS: None. PAST SURGICAL HISTORY: Nasal surger y, knee surgery. (Past medical history) SOCIAL HISTORY: Cigarettes: None. (Social history) FAMILY HISTORY: He does have a family history of melanoma in his paternal grandfather who died from it. (Family history) PHYSICAL EXAMINATION: On examination, he has subcutaneous masses of his left forearm and two spots of his left posterior arm. That is the biggest of those three. It is about 1.3 cm. He has four on his right upper extremity, two on his lower forearm and two on his posterior arm. He has some of his belly. (Organ: Skin) MEDICAL DECISION MAKING: The patient has multiple lipomas (Diagnosis) which are tender. He would like them removed. With his permission, I have drawn how we would incise the skin over these and about how long the scar would be. There is really no alternative to treatment other than surgery. Some plastic surgeons will do this with liposuction, but I have found that personally the recurrence rate is quite high when I have tried to do it with liposuction, so I generally just excise them. Risks would include infection and bleeding. (Elective major surgery (removal of subcutaneous lipoma has a 90-day global); although provider documents risk of infection and bleeding, this is not above the normal risk associated with a surgery.) We do not k now why people get these, so this is something that Mark will have to deal with forever. We will do that here in the office. We will do about three at a time. We are going to start with his left upper extremity. It will be a privilege to take care of Mark. What are the CPT® and ICD -10-CM codes reported? - 99201 D17.21 D17.22 D17.1 CASE 2 Susan is a 67 years -old female and she is referred by Dr. R with a suspicious neoplasm of her left arm.(Chief Complaint) She has had it for about a year but it has grow n a lot this last few months. (Related to surgery.) I had the privilege of taking a skin cancer off her forearm in the past. (Established patient.) PAST MEDICAL HISTORY: Hypertension, arthritis. ALLERGIES: None. MEDICATIONS: Benicar and Vytorin. SOCIAL HISTORY: Cigarettes: None. PHYSICAL EXAMINATION: On examination, she has a raised lesion. It is a little bit reddish and is on her left proximal arm. It has a little bumpiness on its surface. (Related to surgery .) MEDICAL DECISION MAKING: Suspicious neoplasm, left arm. My guess is this is a wart, but it may be a keratoacanthoma (Possible diagnoses are not coded.) as Dr. R thinks it is. After obtaining consent, we infiltrated the area with 1cc of 1% lidocaine with epinephrine, performed a 3 -mm punch biopsy of the lesion, and then I shaved the rest of the lesion off and closed the wound with 3 -0 Prolene.(Punch biopsy and shaving of the lesion are performed.) We will see her back next week to go over the results. What are the CPT® and ICD -10-CM codes reported? - 11300 D49.2 Z85.828 CASE 3 IDENTIFICATION: The patient is a 37 year -old Caucasian lady. CHIEF COMPLAINT: The patient is here today for follow -up (Established patient & established problem.) of lower e xtremity swelling. (Chief complaint) HISTORY OF PRESENT ILLNESS: A 37 year -old with a history of dyslipidemia and chronic pain. (Past medical history) The patient is here for follow -up of bilateral lower extremity (HPI: Location) swelling. The patient tel ls me that the swelling responded to hydrochlorothiazide. (HPI: Modifying factor) EXAM: Very pleasant, no acute distress (NAD). VITALS: P: 67, R: 18, Temp 98.6, BP: 130/85. DATA REVIEW: I did review her labs, (Lab reviewed) and echocardiogram. (Echocardi ogram review) The patient does have moderate pulmonary hypertension. ASSESSMENT: 1. Bilateral lower extremity swelling: This has resolved with diuretics; this may be secondary to problem #2.(Possibly due to pulmonary hypertension, but not certain, so code separately.) 2. Pulmonary hypertension: Etiology is not clear at this time, will do a work up and possible referral to a pulmonologist. PLAN: I think we will need to evaluate the etiology of the pulmonary hypertension. The patient will be scheduled for a sleep study. What are the CPT® and ICD -10-CM codes reported? - 99212 M79.89 I27.20 CASE 4 AGE: 33 year -old - Established patient VITAL SIGNS: TEMPERATURE: 98.9°F Tympanic, PULSE: 97 Right Radial, Regular, BP: 114/70 Right Arm Sitting, PULSE OXIMETRY: 98% , WEIGHT: 161 lbs. CURRENT ALLERGY LIST: LORTAB CURRENT MEDICATION LIST: LUNESTA ORAL TABLET 3 MG, 1 Every Day At Bedtime, As Needed PROZAC ORAL CAPSULE CONVENTIONAL 40 MG, 1 Every Day LEVOTHYROXINE SODIUM ORAL TABLET 100 MCG, 1 Every Day for thyroid MELOXICAM ORAL TABLET 15 MG, 1 Every Day for joint painThe benefits of buying summaries with Stuvia:
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