SOAPNote: 4:a3f87b84-9ee7-4c47-aed0-1f8e293aa4a0:56985
| note_id | โ |
| mrn | 6734 |
| date | 2026-04-08 |
| session_date | โ |
| em_code | 99213 |
| char_count | 2797 |
| generator | claude-code-direct |
| generated_at | 2026-04-09T00:07:40.626000000+00:00 |
| icd10_codes | ["D22.9 (Melanocytic nevi, unspecified)", "L57.0 (Actinic keratosis)", "Z85.828 (Personal history of other malignant neoplasm of skin)", "D48.5 (Neoplasm of uncertain behavior of skin)"] |
| cpt_codes | ["99213 (E/M level 3, established patient)", "96904 (Whole body integumentary photography)"] |
| mips_json | {"509": {"status": "N/A", "evidence": "No melanoma history"}, "317": {"status": "PENDING", "evidence": "BP screening at visit"}, "357": {"status": "N/A", "evidence": "No dermatologic surgical procedure today"}, "374": {"status": "N/A", "evidence": "No open referral loop"}, "485": {"status": "N/A", "evidence": "No psoriasis diagnosis"}, "486": {"status": "N/A", "evidence": "No dermatitis diagnosis"}} |
| full_note | SOAP/MIPS NOTE - Lynch, Arlene (MRN 6734) Date of Service: 2026-04-08 DOB: 12/12/1939 Provider: Drugge, RJ MD Visit Type: Established Patient, Full Body Scan S: Patient presents for scheduled Melanoscan whole-body photography visit. Routine skin cancer screening with total body photography. Patient has 20 prior biopsy records on file. Prior melanoscan sessions: 4. No acute complaints reported at check-in. O: PHYSICAL EXAM Whole Body Integumentary Photography performed with Melanoscan multi-camera array. Total lesions detected (CNN classification): 1,013 Longitudinal scan sessions: 4 Dermoscopy images on file: 49 CNN Risk Stratification: Lesions with MEL score > 0.50: 1 Lesions with MEL score > 0.30: 1 Lesions with BCC score > 0.50: 151 Maximum MEL score: 0.5203 Maximum BCC score: 0.8930 Dermoscopy max MEL: 0.4131 High-Risk Regional Distribution: View D1: 1 spots, max MEL=0.5203, max BCC=0.0204 Pathology History (20 records): 2025-05-09: - Dx: 2025-05-09: - Dx: 2025-05-09: - Dx: 2025-05-09: - Dx: 2025-05-09: - Dx: 2025-05-09: Left cheek - Dx: BOWEN'S DISEASE (SQUAMOUS CELL CARCINOMA IN SITU), INFLAMED AND IMPETIGINIZED 2025-05-09: Right temple - Dx: ACTINIC KERATOSIS 2019-08-06: - Dx: A: ASSESSMENT 1. D22.9 - Multiple melanocytic nevi. Full body surveillance indicated. 2. D48.5 - Neoplasm of uncertain behavior of skin. 1 lesions with CNN MEL > 0.50 warrant further evaluation. 3. L57.0 - Actinic keratosis screening. High BCC scores (151 lesions > 0.50) noted in multiple regions. Medical Necessity: Whole body photography (CPT 96904) is medically necessary for longitudinal change detection in patient with 1,013 tracked lesions. P: PLAN 1. Routine surveillance - CSC scan completed. Next scan per risk stratification. 2. Review 1 high-MEL lesions with senior dermatologist for potential biopsy decision. 3. Patient education: Sun protection counseling, self-skin examination instruction. 4. Follow-up: 12 months for repeat Melanoscan. ICD-10: D22.9 (Melanocytic nevi, unspecified) L57.0 (Actinic keratosis) Z85.828 (Personal history of other malignant neoplasm of skin) D48.5 (Neoplasm of uncertain behavior of skin) CPT: 99213 (E/M level 3, established patient) 96904 (Whole body integumentary photography) MIPS Report: { "509": { "status": "N/A", "evidence": "No melanoma history" }, "317": { "status": "PENDING", "evidence": "BP screening at visit" }, "357": { "status": "N/A", "evidence": "No dermatologic surgical procedure today" }, "374": { "status": "N/A", "evidence": "No open referral loop" }, "485": { "status": "N/A", "evidence": "No psoriasis diagnosis" }, "486": { "status": "N/A", "evidence": "No dermatitis diagnosis" } } |
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