SOAPNote: 4:a3f87b84-9ee7-4c47-aed0-1f8e293aa4a0:56989
| note_id | โ |
| mrn | 32943 |
| date | 2026-04-08 |
| session_date | โ |
| em_code | 99215 |
| char_count | 2975 |
| generator | claude-code-direct |
| generated_at | 2026-04-09T00:07:40.632000000+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 | ["99215 (E/M level 5, 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 - Gregory, Gregg (MRN 32943) Date of Service: 2026-04-08 DOB: 05/12/1955 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 7 prior biopsy records on file. Prior melanoscan sessions: 5. 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): 9,472 Longitudinal scan sessions: 5 Dermoscopy images on file: 29 CNN Risk Stratification: Lesions with MEL score > 0.50: 19 Lesions with MEL score > 0.30: 76 Lesions with BCC score > 0.50: 240 Maximum MEL score: 0.9198 Maximum BCC score: 0.9147 Dermoscopy max MEL: 0.1136 High-Risk Regional Distribution: View D2: 187 spots, max MEL=0.9198, max BCC=0.6551 View D3: 164 spots, max MEL=0.6924, max BCC=0.6747 View J3: 158 spots, max MEL=0.6335, max BCC=0.6965 View A2: 262 spots, max MEL=0.5988, max BCC=0.6834 View F2: 222 spots, max MEL=0.5881, max BCC=0.7291 Pathology History (7 records): 2021-01-13: Left parietal scalp - Dx: SKIN, LEFT PARIETAL SCALP, SHAVE AND ELECTRODESICCATION AND CURETTAGE:INVASIVE S 2021-01-13: - Dx: 2021-01-13: - Dx: 2021-01-13: - Dx: 2021-01-13: - Dx: 2021-01-13: - Dx: 2021-01-13: - Dx: A: ASSESSMENT 1. D22.9 - Multiple melanocytic nevi. Full body surveillance indicated. 2. D48.5 - Neoplasm of uncertain behavior of skin. 19 lesions with CNN MEL > 0.50 warrant further evaluation. 3. L57.0 - Actinic keratosis screening. High BCC scores (240 lesions > 0.50) noted in multiple regions. Medical Necessity: Whole body photography (CPT 96904) is medically necessary for longitudinal change detection in patient with 9,472 tracked lesions. P: PLAN 1. Routine surveillance - CSC scan completed. Next scan per risk stratification. 2. Review 19 high-MEL lesions with senior dermatologist for potential biopsy decision. 3. Patient education: Sun protection counseling, self-skin examination instruction. 4. Follow-up: 6 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: 99215 (E/M level 5, 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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