3/10/xx Jacob Bond, MD
Patient in for follow-up appointment status-post mastectomy on 2/10/xx. Hospital course was complicated by atrial fibrillation and embolism, requiring embolectomy. Patient also developed pleural effusion requiring pleuracentesis. Patient has now been discharged from the hospital for 10 days. Other than some incisional pain, patient seems to be doing well. No major complaints: denies shortness of breath, nausea loss of appetite, fever, or pain in extremities. Energy levels seems to be returning to normal. Incision sites are examined, with no erythema or infection notes. Sutures removed. Patient is instructed not to lift, push or pull objects and to return to activities slowly. Wound care is reviewed. Patient is instructed to follow-up 2 weeks or sooner if complaints.
Since the patient is only there fora post-operative visit. The coder should locate the main term "Post-Op Visit." The coder is should review the code in the CPT medicine section. After carefully reviewing the code the coder should select 99024