1. Emergency Room: Patient Name: Charles Teal
Date of visit: 1/4/2019
Age: 50
Sex: Male
Insurance: HMO

Emergency Room Visit:

Date: 1/4/2019
Chief complaint: Cyst on groin area for several days
History of present illness: Patient complains of a tender swollen spot in the perirectal region. This has occurred for several days. It is painful and it is getting worse as time progresses.

Past medical history: negative for diabetes or hypertension

Medications: none

Allergies: ASA

Social history: patient smokes one packet per day

Review of symptoms: All negative

Physical Examination:
General: Patient is alert & orientated x 3. Patient is in moderate distress.
Vitals: BP: 130/80; P:111; R:21; T:100
Skin: There is a fluctuant abscess in the scrotal area, which needs to be drained.

Procedure: Skin was prepped with betadine, and lidocaine 1% was given. The abscess was incised with a #11 knife and a large amount of pus drained. The area was irrigated with saline and packed with gauze.

Impression: Abscess of the scrotal wall

Discharge instruction: patient is to follow up in 3 days for removal of the gauze. Patient is to take Tylenol if needed for pain.

History: Problem-focused
Physical exam: problem-focused
Medical Decision: straight-forward

What is the diagnosis codes & procedure codes?

Diagnosis Code(s):

Procedure Code(s) (CPT):