Please create a SOAP note for a 9-year-old male with persistent warts on the hand, abdomen, and great toe who could not tolerate office cryotherapy (second attempt today), and include a dermatology referral, CPT codes, and ICD‑10‑CM codes.

SOAP Note: 9-Year-Old Male with Persistent Warts

Subjective

• 9-year-old male returns for persistent warts on hand, abdomen (stomach), and toe
• Failed two attempts at in-office cryotherapy due to inability to tolerate the procedure
• Pain/discomfort preventing completion of freezing treatment

Objective

• Multiple verrucae present on:
  • Hand (verruca vulgaris)
  • Abdomen (likely verruca plana - plane warts)
  • Toe (verruca vulgaris)
• Patient unable to tolerate cryotherapy during today's visit (second failed attempt)
• No signs of secondary infection or inflammation noted

Assessment

Primary Diagnoses:

• B07.8 - Viral warts, multiple sites
• B07.9 - Viral wart, unspecified (if coding individually)

Alternative specific codes if needed:

• B07.0 - Plantar wart (if toe lesion is plantar)
• Hand and abdominal warts: B07.8 or B07.9

Plan

Given this child's inability to tolerate cryotherapy, topical salicylic acid (15-26%) is the appropriate first-line alternative treatment 1. The British Association of Dermatologists guidelines specifically recommend salicylic acid as a Grade A treatment for hand warts and note that painful treatments should be avoided in young children when possible 1.

Treatment Recommendations:

1. Initiate topical salicylic acid 15-26% applied daily after paring/removing thick keratin layer, with occlusion if possible 1

   • Continue for 3-4 months minimum
   • This is painless and appropriate for pediatric patients who cannot tolerate destructive methods 1

2. Dermatology referral for:

   • Consideration of alternative painless therapies if salicylic acid fails
   • Potential options include: topical immunotherapy (contact sensitization), imiquimod 5% cream, or pulsed-dye laser (which may be better tolerated than cryotherapy) 1
   • Plane warts on abdomen may require different approach (lower concentration SA 2-10% or retinoids) 1

3. Counseling provided:

   • Warts in children often clear spontaneously within 1-2 years 1
   • Avoid picking/scratching to prevent autoinoculation
   • No swimming pools or walking barefoot until resolved (common transmission routes) 2

Follow-up:

• Return in 6-8 weeks to assess response to salicylic acid
• Dermatology appointment pending

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CPT Codes

Office Visit:

• 99213 - Established patient, level 3 (straightforward medical decision making; failed treatment attempt, new plan initiated, specialist referral)
• OR 99214 - Established patient, level 4 (if more extensive counseling/coordination of care documented, >20 minutes)

Procedure (if attempted):

• 17110 - Destruction of benign lesions, first lesion (if any cryotherapy was attempted before patient could not tolerate)
• Add 17111 for each additional lesion if multiple sites treated

Note: If cryotherapy was completely not performed due to intolerance, only bill the E/M code.

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ICD-10-CM Codes

Primary:

• B07.8 - Viral warts, multiple sites (most appropriate for this case)

Alternative/Additional codes:

• B07.9 - Viral wart, unspecified
• B07.0 - Plantar wart (if toe lesion is on plantar surface)

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Clinical Pearls:

• Cryotherapy intolerance is common in pediatric patients - the British guidelines explicitly state painful treatments should be avoided in young children 1
• Salicylic acid has Grade A evidence for hand warts and is painless, making it ideal for this scenario 1
• Cure rates vary by location: hand warts respond better (78.67%) than foot warts (70.52%) 2
• Plane warts on abdomen may require gentler approach with lower SA concentrations (2-10%) to avoid scarring on cosmetically sensitive areas 1
• Recurrence rate is approximately 11% even after successful treatment 2