Code the following physician encounters using ICD-9-CM, ICD-10-CM, and CPT. Sequence the codes in the correct order. Assign any needed modifiers.
PHYSICIAN OFFICE VISIT
PATIENT: ROBERTOFFICE
RECORDNUMBER: 11-68-23
DATEOFSERVICE: 09-1-XX
PHYSICIAN: DR. KIM. M. D.
SUBJECTIVE: This is a 77-year-old new patient who presents to the office to have a lesion checked on his right forearm. He has noticed it in the last 2months or so, and it has been growing fairly rapidly. It has not bled and does not bother him at all. No other recent skin issues. The patient does have a history of basal cell skin cancers on his nose and check 4 years ago, which were treated with recurrence. The patient feels well and has no other issues or concerns.
OBJECTIVE: Alert male in no distress. SKIN: Examination of his right foream shows a lesion on the radial aspect of the proximal part of the forearm. It is 2 cm in size and is raised about 4 mm. It is slightly red and irritated appearing, though there is no ulceration. It was noted that the patient's blood pressure is a bit elevated today. The patient is to follow up with me in the next month or two to recheck elevated blood pressure and address if necessary.
ASSESSMENT: Abnormal skin lesions right forearm, probably keratoacanthoma.
PLAN: After verbal informed consent was obtained, the lesion was prepped with alcohol, anesthetized with 2% lidocaine with epinephrine. Shave biopsy was then performed. Tissue was sent to pathology. Hemostasis was with 35% aluminum chloride. The patient tolerated the procedure well. The skin was covered with a bandage.
PATHOLOGY returned as keratoacanthoma.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
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