OUTPATIENT ICD-9 AND ICD-10-CM CODING

Dermatology Reports

Medical Specialty: Dermatology

Pilonidal cyst - Excision

Description:

Pilonidal cyst with abscess formation. Excision of infected pilonidal cyst.

PREOPERATIVE DIAGNOSIS:

Pilonidal cyst with abscess formation.

POSTOPERATIVE DIAGNOSIS:

Pilonidal cyst with abscess formation.

OPERATION:

Excision of infected pilonidal cyst.

PROCEDURE:

After obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operating room. A time-out process was followed. Antibiotics were given and then the patient was prepped and draped in the usual fashion. It appeared to me that the abscess had drained somewhat during the night, as it was much smaller than I was anticipating. An elliptical excision of all infected tissues down to the coccyx was performed. Hemostasis was achieved with a cautery. The wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing.

The patient was sent to recovery room in satisfactory condition. Estimated blood loss was minimal. The patient tolerated the procedure well.

  • 685.1; L05.91; 11771
  • 685.0; L05.01; 11770
  • 685.1; L05.92; 11772
  • 685.0; L05.02; 11770

Answer

Hand dermatitis

Description:

Hand dermatitis.

SUBJECTIVE:

This is a 29 year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04. She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema. I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion. She comes in today for reevaluation because she is flaring. Her hands are very dry, they are cracked, she has been washing with soap. She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin. She has been wearing some gloves also apparently. The patient is single. She is unemployed.

FAMILY, SOCIAL, AND ALLERGY HISTORY: The patient has asthma, sinus, hives, and history of psoriasis. No known drug allergies.

MEDICATIONS:

The patient is a nonsmoker. No bad sunburns or blood pressure problems in the past.

CURRENT MEDICATIONS:

Claritin and Zyrtec p.r.n.

PHYSICAL EXAMINATION:

The patient has very dry, cracked hands bilaterally.

IMPRESSION:

Hand dermatitis.

TREATMENT:

  • Discussed further treatment with the patient and her interpreter.
  • 2. Apply Aristocort ointment 0.1% and equal part of Polysporin ointment t.i.d. and p.r.n. itch.
  • 3. Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion.
  • 4. Keflex 500 mg b.i.d. times two weeks with one refill. Return in one month if not better; otherwise, on a p.r.n. basis and send Dr. XYZ a letter on this office visit.
  • 782.8; R23.4
  • 782.9; R23.8
  • 701.1; L85.0
  • 706.8; L85.3

Answer

Onychocryptosis

Description:

An 83 year-old female presents today for foot care.

S - An 83 year-old female presents today for foot care.

O - On examination, the lateral aspect of her left great toenail is deeply ingrown. Her toenails are thick and opaque. Vibratory sensation appears to be intact. Dorsal pedal pulses are 1/4. There is no hair growth seen on her toes, feet or lower legs. Her feet are warm to the touch. All of her toenails are hypertrophic, opaque, elongated and discolored.

A -
  • Onychocryptosis.
  • Onychomycosis.
  • Difficulty in walking. The patients' toenails have made wearing shoe gear painful.

P -

Aseptic technique was used and the lateral aspect of the left great toenail plate was excised. Blood loss was minimal. Hemostasis was achieved. Her left great toe was dressed with Neosporin ointment and absorbent dressing. Her remaining toenails required manual as well as electric debridement. Followup is every three months or whenever she needs to come in.

  • 703.8, 110.4; L60.3, B35.3; 11719
  • 702.8, 110.8; L98.8, B35.8; 11730, 11732
  • 703.9, 110.6; L60.9, B35.8; 11761, 11721-51
  • 703.0, 110.1; L60.0, B35.1; 11730, 11721-51

Answer

Condyloma - Cauterization

Description:

Cauterization of peri and intra-anal condylomas. Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.

PREOPERATIVE DIAGNOSIS:

Extensive perianal and intra-anal condyloma.

POSTOPERATIVE DIAGNOSIS:

Extensive perianal and intra-anal condyloma.

PROCEDURE PERFORMED:

Cauterization of peri and intra-anal condylomas.

ANESTHESIA:

IV sedation and local.

SPECIMEN:

Multiple condylomas were sent to pathology.

ESTIMATED BLOOD LOSS:

10 cc.

BRIEF HISTORY:

This is a 22 year-old female, who presented to the office complaining of condylomas she had noted in her anal region. She has noticed approximately three to four weeks ago. She denies any pain but does state that there is some itching. No other symptoms associated.

GROSS FINDINGS:

We found multiple extensive perianal and intra-anal condylomas, which are likely represent condyloma acuminata.

PROCEDURE:

After risks, benefits and complications were explained to the patient and a verbal consent was obtained, the patient was taken to the operating room. After the area was prepped and draped, a local anesthesia was achieved with Marcaine. Bovie electrocautery was then used to remove the condylomas taking care to achieve meticulous hemostasis throughout the course of the procedure. The condylomas were removed 350 degrees from the perianal and intra-anal regions. After all visible condylomas were removed, the area was again washed with acetic acid solution. Any residual condylomas were then cauterized at this time. The area was then examined again for any residual bleeding and there was none.

DISPOSITION:

The patient was taken to Recovery in stable condition. She will be sent home with prescriptions for a topical lidocaine and Vicodin. She will be instructed to do sitz bath b.i.d., and post-bowel movement. She will follow up in the office next week.

  • 078.10; B07.9; 46900
  • 078.11; A63.0; 46924
  • 078.12; B07.0; 46910
  • 078.11; A63.0; 46917

Answer

Actinic keratosis - Biopsy

Description:

Excisional biopsy of actinic keratosis, two-layer and one-layer plastic closures.

PREOPERATIVE DIAGNOSES:

  • Left chest actinic keratosis, 2 cm.
  • Left medial chest actinic keratosis, 1 cm.
  • Left shoulder actinic keratosis, 1 cm.

POSTOPERATIVE DIAGNOSES:

  • Left chest actinic keratosis, 2 cm.
  • Left medial chest actinic keratosis, 1 cm.
  • Left shoulder actinic keratosis, 1 cm.

TITLE OF PROCEDURES:

  • Excisional biopsy of left chest 2 cm actinic keratosis.
  • Two-layer plastic closure.
  • Excisional biopsy of left chest medial actinic keratosis 1 cm with one-layer plastic closure.
  • Excisional biopsy of left shoulder actinic keratosis, 1 cm, one-layer plastic closure.

ANESTHESIA:

Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 6 mL.

ESTIMATED BLOOD LOSS:

Minimal.

COMPLICATIONS:

None.

PROCEDURE:

All areas were prepped, draped, and localized in the usual manner. Afterwards, elliptical incisions were placed with a #15-blade scalpel and curved iris scissors and small bishop forceps were used for the dissection of the skin lesions. After all were removed, they were closed with one-layer technique for the shoulder and medial lesion, and the larger left chest lesion was closed with two-layer closure using Monocryl 5-0 for subcuticular closure and 5-0 nylon for skin closure. She tolerated this procedure very well, and postoperative care instructions were provided. She will follow up next week for suture removal. Of note, she had an episode of hemoptysis, which could not be explained prompting an emergency room visit, and I discussed if this continues we may wish to perform a fiberoptic laryngoscopy examination and possible further workup if a diagnosis cannot be made.

  • 702.11, 786.39; L82.0, R04.89; 11404
  • 701.8, 786.39; L91.8, R04.89; 11400, 12032
  • 702.0, 786.30; L57.0. R04.2; 11404, 12031
  • 702.19, 786.2; L82.1, R05; 11404

Answer

Poison ivy

Description:

Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.

SUBJECTIVE:

He is a 24 year-old male who said that he had gotten into some poison ivy this weekend while he was fishing. He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg. He said that it worked fairly well, although it seemed to still take awhile to get rid of it. He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.

OBJECTIVE:

Vitals:

Temperature is 99.2. His weight is 207 pounds.

Skin:

Examination reveals a raised, maculopapular rash in kind of a linear pattern over his arms, legs and chest area which are consistent with a poison ivy or a poison oak.

ASSESSMENT AND PLAN:

Poison ivy. Continue over-the-counter Benadryl or Rx allergy medicine that he was given the last time he was here, which is a one-a-day allergy medicine; he cannot exactly remember what it is, which would also be fine rather than the over-the-counter Benadryl if he would like to use that instead.

  • 692.6; L23.7
  • 691.8; L20.89
  • 692.5; L25.4
  • 782.1; R21

Answer

Abdominal Abscess - I&D

Description:

Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle.

PREOPERATIVE DIAGNOSIS:

Abdominal wall abscess.

POSTOPERATIVE DIAGNOSIS:

Abdominal wall abscess.

PROCEDURE:

Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle.

ANESTHESIA:

LMA.

INDICATIONS:

Patient is a pleasant 60 year-old gentleman, who initially had a sigmoid colectomy for diverticular abscess 10 days ago. He subsequently had a dehiscence with evisceration. He came to the ER approximately 36 hours ago with pain across his lower abdomen. CT scan demonstrated presence of an abscess beneath the incision. It was recommended to the patient he undergo the above-named procedure and he presents for the procedure to be done at this time. Procedure, purpose, risks, expected benefits, potential complications, alternatives forms of therapy were discussed with him, and he was agreeable to surgery.

FINDINGS:

The patient was found to have an abscess that went down to the level of the fascia. The anterior layer of the fascia was fibrinous and some portions necrotic. This was excisionally debrided using the Bovie cautery, and there were multiple pieces of suture within the wound and these were removed as well.

TECHNIQUE:

Patient was identified, then taken into the operating room, where after induction of appropriate anesthesia, his abdomen was prepped with Betadine solution and draped in a sterile fashion. The wound opening where it was draining was explored using a curette. The extent of the wound marked with a marking pen and using the Bovie cautery, the abscess was opened and drained. I then noted that there was a significant amount of undermining. These margins were marked with a marking pen, excised with Bovie cautery; the curette was used to remove the necrotic fascia. The wound was irrigated; cultures sent prior to irrigation and after achievement of excellent hemostasis, the wound was packed with antibiotic-soaked gauze. A dressing was applied. The finished wound size was 9.0 x 5.3 x 5.2 cm in size. Patient tolerated the procedure well. Dressing was applied, and he was taken to recovery room in stable condition.

  • 682.2, 998.4; L03.319, T81.500A; 11000
  • 682.2, 998.33; L02.211, T81.33XA; 11042, 11045, 11045
  • 682.2, 998.59; L02.211, T81.4XXA; 11005
  • 682.8; L03.818; 11004

Answer

Facial rhytids

Description:

Evaluation and recommendations regarding facial rhytids.

HISTORY:

This 57 year-old female who presented today for evaluation and recommendations regarding facial rhytids. In summary, the patient is a healthy 57 year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds.

RECOMMENDATIONS:

I do believe a facelift procedure would be of maximum effect for the patient's areas of concern and a "quick lift" type procedure certainly would address these issues. I went over risks and benefits with the patient along with the preoperative and postoperative care, and risks include but are not limited to bleeding, infection, discharge, scar formation, need for further surgery, facial nerve injury, numbness, asymmetry of face, problems with hypertrophic scarring, problems with dissatisfaction with anticipated results, and she states she will contact us later in the summer to possibly make arrangements for a quick lift through Memorial Medical Center.

  • 692.70; L57.8
  • 709.8; L98.8
  • 695.3; L71.9
  • 706.2; L72.0

Answer

Itchy rash

Description:

This 34 year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.

CHIEF COMPLAINT:

Itchy rash.

HISTORY OF PRESENT ILLNESS:

This 34 year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breath, wheezing, or other associated symptoms. He cannot think of anything that could have triggered this off. There have been no changes in his foods, medications, or other exposures as far as he knows. He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.

PAST MEDICAL HISTORY:

Negative for chronic medical problems. No local physician. Has had previous back surgery and appendectomy, otherwise generally healthy.

REVIEW OF SYSTEMS:

As mentioned denies any oropharyngeal swelling. No lip or tongue swelling. No wheezing or shortness of breath. No headache. No nausea. Notes itchy rash, especially on his torso and upper arms.

SOCIAL HISTORY:

The patient is accompanied with his wife.

FAMILY HISTORY:

Negative.

MEDICATIONS:

None.

ALLERGIES:

TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN.

PHYSICAL EXAMINATION:

VITAL SIGNS: The patient was afebrile. He is slightly tachycardic, 105, but stable blood pressure and respiratory rate. GENERAL: The patient is in no distress. Sitting quietly on the gurney. HEENT: Unremarkable. His oral mucosa is moist and well hydrated. Lips and tongue look normal. Posterior pharynx is clear. NECK: Supple. His trachea is midline. There is no stridor. LUNGS: Very clear with good breath sounds in all fields. There is no wheezing. Good air movement in all lung fields. CARDIAC: Without murmur. Slight tachycardia. ABDOMEN: Soft, nontender. SKIN: Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms. He noted some on his buttocks as well. Remaining of the exam is unremarkable.

ED COURSE:

The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly. After about 15-20 minutes he states that itching started to feel better. The rash has started to fade a little bit and feeling a lot more comfortable.

IMPRESSION:

ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS.

ASSESSMENT AND PLAN:

The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess. He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off. In the meantime, I think he can be managed with some antihistamine over-the-counter. He is responding already to Benadryl and the epinephrine that we gave him here. He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation. He is discharged in stable condition.

  • 705.0, 698.8; L74.2, L29.8; J1020, J1200
  • 708.0, 698.9; L50.0, L29.9; 96372; J0171, J1200
  • 708.2, 698.8; L50.2, L29.8; 90471, 90472
  • 708.8, 698.9; L50.6, L29.9; 90460, 90461; J0171, J1200

Answer

Wasp sting

Description:

Comes in complaining that he was stung by a yellow jacket wasp yesterday and now has a lot of swelling in his right hand and right arm.

SUBJECTIVE:

He is a 29 year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a yellow jacket wasp yesterday and now has a lot of swelling in his right hand and right arm. He says that he has been stung by wasps before and had similar reactions. He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past. He has had a lot of swelling, but no anaphylaxis-type reactions in the past; no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past; no racing heart beat or anxiety feeling, just a lot of localized swelling where the sting occurs.

OBJECTIVE:

Vitals:

His temperature is 98.4. Respiratory rate is 18. Weight is 250 pounds.

Extremities:

Examination of his right hand and forearm reveals that he has an apparent sting just around his wrist region on his right hand on the medial side as well as significant swelling in his hand and his right forearm; extending up to the elbow. He says that it is really not painful or anything like that. It is really not all that red and no signs of infection at this time.

ASSESSMENT:

Yellow jacket wasp sting to the right wrist area.

PLAN:

  • Solu-Medrol 125 mg IM X 1.
  • Over-the-counter Benadryl, ice and elevation of that extremity.
  • Follow up with Dr. XYZ if any further evaluation is needed.
  • 989.5, E905.3; T63.461A; 96372; J2930
  • 989.5, E905.6; T63.451A; 96401; J1030
  • 989.5, E906.4; T63.441A; 90460; J2920
  • 989.5, E905.2; T63.464A; 96372; J1040

Answer