[Verified Answer]: A patient presents for an I&D of a…

A patient presents for an I&D of a sebaceous cyst on her left thigh. The procedure was performed without incident, and she tolerated it well. She is noticing, however, that she has been having more and more headaches lately. She keeps a headache diary. Her last one was three days ago and included aura. She took Motrin without relief. She is not noticing any food triggers or activity triggers. She is premenopausal. On exam her vitals are stable. PERRLA; no lymph nodes upon palpation. Her skin is normal in color and turgor. RRR. Chest is CTAB. Abdomen is soft, non-tender. No edema. The patient is alert, attentive, and oriented. Speech is clear and fluent with good repetition, comprehension, and naming. She recalls 3/3 objects at 5 minutes. CN II: Visual fields are full to confrontation. Fundoscopic exam is normal with sharp discs and no vascular changes. Venous pulsations are present bilaterally. Pupils are 4 mm and briskly reactive to light. Visual acuity is 20/20 bilaterally. CN III, IV, VI: At primary gaze, there is no eye deviation. CN V: Facial sensation is intact to pinprick in all 3 divisions bilaterally. Corneal responses are intact. CN VII: Face is symmetric with normal eye closure and smile. CN VII: Hearing is normal to rubbing fingers. CN IX, X: Palate elevates symmetrically. Phonation is normal. CN XI: Head turning and shoulder shrug are intact. CN XII: Tongue is midline with normal movements and no atrophy. There is no pronator drift of out-stretched arms. Muscle bulk and tone are normal. Strength is full bilaterally. I have recommended she see a neurologist, and I ordered an EEG for her prior to her going to that appointment.” After reviewing the medical record excerpt, do you find evaluation and management services that transcend those inherent to the incision and drainage procedure? Explain why or why not. If you did find evaluation and management services that transcend those inherent to the procedure, identify the history elements that transcend those inherent to the procedure. If you did find evaluation and management services that transcend those inherent to the procedure, identify the exam elements that transcend those inherent to the procedure. How might the documentation for this encounter be improved? Report the correct codes—procedure and diagnosis codes—for the services rendered by the provider creating this note.