This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks’ duration.

CHART NOTE

CC: This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks’ duration.

EXAMINATION: This is a 50-year-old male in apparent good health. His BP is 119/78. Rectal examination showed a Grade I hemorrhoid in the 2 o’clock position approximately 2 cm across. The area around the hemorrhoid was slightly inflamed and a small amount of blood was noted.

ASSESSMENT: Hemorrhoid.

PLAN: Discuss with conservative treatment options with the patient and explained surgical option. He wants to try the more conservative approach of stool softeners, and warm sitz baths. I discussed with him the importance of improved bowel habits. He is to return for a recheck in 2 months. The physician documents a total of 14 minutes spent with the patient. 

whats the cpt code?

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