SOAPNote: 4:a3f87b84-9ee7-4c47-aed0-1f8e293aa4a0:56995
| note_id | โ |
| mrn | 44187 |
| date | 2026-04-08 |
| session_date | โ |
| em_code | 99214 |
| char_count | 2858 |
| generator | claude-code-direct |
| generated_at | 2026-04-09T00:07:40.641000000+00:00 |
| icd10_codes | ["D22.9 (Melanocytic nevi, unspecified)", "L57.0 (Actinic keratosis)", "D48.5 (Neoplasm of uncertain behavior of skin)"] |
| cpt_codes | ["99214 (E/M level 4, 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 - Giannuzzi, Louis (MRN 44187) Date of Service: 2026-04-08 DOB: 11-12-1931 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: 3. 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): 3,663 Longitudinal scan sessions: 3 Dermoscopy images on file: 5 CNN Risk Stratification: Lesions with MEL score > 0.50: 70 Lesions with MEL score > 0.30: 223 Lesions with BCC score > 0.50: 59 Maximum MEL score: 0.8202 Maximum BCC score: 0.8862 Dermoscopy max MEL: 0.4249 High-Risk Regional Distribution: View C2: 91 spots, max MEL=0.8202, max BCC=0.6647 View B2: 70 spots, max MEL=0.7926, max BCC=0.3688 View G3: 92 spots, max MEL=0.7596, max BCC=0.6978 View D3: 70 spots, max MEL=0.7317, max BCC=0.7054 View D2: 105 spots, max MEL=0.7206, max BCC=0.7607 Pathology History (7 records): 2025-05-16: right flank - Dx: PERIVASCULAR DERMATITIS WITH EOSINOPHILS 2025-05-16: - Dx: 2025-05-16: - Dx: 2025-05-16: - Dx: 2025-05-16: - Dx: 2025-05-16: - Dx: 2025-05-16: - Dx: A: ASSESSMENT 1. D22.9 - Multiple melanocytic nevi. Full body surveillance indicated. 2. D48.5 - Neoplasm of uncertain behavior of skin. 70 lesions with CNN MEL > 0.50 warrant further evaluation. 3. L57.0 - Actinic keratosis screening. High BCC scores (59 lesions > 0.50) noted in multiple regions. Medical Necessity: Whole body photography (CPT 96904) is medically necessary for longitudinal change detection in patient with 3,663 tracked lesions. P: PLAN 1. Routine surveillance - CSC scan completed. Next scan per risk stratification. 2. Review 70 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) D48.5 (Neoplasm of uncertain behavior of skin) CPT: 99214 (E/M level 4, 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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