I have a doubt whether this can be coded based on 95 guideline or 97 guideline. I need an assistance.
Physical Examination.
General:
Build obese. General appearance happy, no acute distress, alert and oriented to person, place and time, pleasant, well hydrated, well nourished. LMP 03/11/2017-post.
Skin Eruption:
Site scalp. Distribution Localized. Description SebDerm- Erythematous, scaly patches noted. Scale appears loosely adhered and greasy. Condition status Patient with moderate improvement .
Skin Eruption-Additional:
Site bilateral arms and legs, trunk. Distribution Scattered. Description Xerosis- Diffuse and scattered skin involvement with barely visible scaling roughness of skin. There are diffuse excoriations noted secondary to the associated pruritis. There are areas of fine scales and hyperkeratosis observed sparing the flexural folds. Slight fissuring is noted. Condition status Patient with moderate improvement noted.