AAPC - Chapter 19 Practical Applications
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 surgery, 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 o - correct answer 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 grown 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, perform - correct answer 11300
D49.2
Z85.828
CASE 3
IDENTIFICATION: The patient is a 37 year-old Caucasian lady.
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 surgery, 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 o - correct answer 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 grown 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, perform - correct answer 11300
D49.2
Z85.828
CASE 3
IDENTIFICATION: The patient is a 37 year-old Caucasian lady.
