This 49-year-old female is complaining of painful mouth ulcers for the past month.
6.60) This 49-year-old female is complaining of painful mouth ulcers for the past month. She has previously been treated with acyclovir and penicillin on two occasions. Although she indicates that she feels better, the patient continues to have ulcers with pain. She does deny fever, chills, dysphagia, or lymphadenopathy.
Physical Exam: Reveals whitish patches measuring 1mm; three 1mm patches on the buccal mucosa and the hard plate. They are erythematous and inflamed.
Assessment: Aphthous ulcers and herpangina
Plan: Will start the patient on oral clindamycin for buccal cellulitis and Amlexanox 5 percent as oral paste along with the Xylocaine mouthwash. The patient should follow up with me in two weeks.
Assign the correct codes: ICD-10-CM:
6.61) Chief Complaint: Warts on the sole of the right foot
The 12-year-old male patient is seen with complaints of painful warts on the sole of the right foot. He states that warts first appeared about three weeks ago but have become progressively painful. The patient was seen in the office two months ago with chronic otitis media, and he had no problems at that time with warts. The physical examination of the bottom of the right foot reveals four separate lesions of the following sizes and locations 4-mm verruca on the heel of the foot, two 3-mm verruca on the ballot of the foot, and a 6-mm verrucous papule near the base of the big toe.
Initial impression: Plantar warts
After consent from the mother, cryocautery was used to destroy each of the lesions. The patient experienced minor discomfort, which abated soon after. The wounds were dressed, and the patient was advised to make an appointment for one week.
Which codes are used to report this office visit?
ICD-10-CM and CPT codes:
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