# Clamshell



## KristieStokesCPC (Sep 2, 2008)

Does anyone know if we can bill for a clamshell? I attached the note below for clarafication:

SUBJECTIVE:

CC: 
Patient is a 46-year-old female.  She presents with left ankle / right knee pain / trauma on 8-02-08.  

HPI: 
Patient presents today with complaints of left ankle pain and right knee pain.  She fell at a gas station early in the morning off the curb two days ago.  She was able to walk, and they were in the process of moving their son to college in Tallahassee.  She drove one of the vehicles and was there overnight helping him unpack and move in.  She was really unable to stay off of it until today.  She put ice on it last evening.  She complains they are both very sore and her knee is quite swollen. 

ROS: 
CONSTITUTIONAL:  Positive for unintentional weight gain.   Negative for chills, fatigue, fever, night sweats or unintentional weight loss.  
EYES:  Negative for blurred vision.  
E/N/T:  Positive for nasal congestion.   Negative for ear pain, diminished hearing, tinnitus, frequent epistaxis, frequent rhinorrhea, bleeding gums, periodontal disease, hoarseness or sore throat.  
CARDIOVASCULAR:  Negative for chest pain, claudication, dizziness, orthopnea, palpitations, pedal edema, tachycardia and varicosities.  
RESPIRATORY:  Negative for recent cough, chronic cough, dyspnea, exposure to tuberculosis, hemoptysis, pleuritic chest pain and frequent wheezing.  
GASTROINTESTINAL:  Negative for abdominal pain, acid reflux symptoms, anorexia, dysphagia, constipation, diarrhea, heartburn, hematemesis, hematochezia, hemorrhoids, melena, nausea and vomiting.  
MUSCULOSKELETAL:  Negative for arthralgias and myalgias.  
INTEGUMENTARY/BREAST:  Negative for atypical mole(s), breast mass, skin changes of breast, breast tenderness and nipple discharge.  
NEUROLOGICAL:  Negative for ataxia, dizziness, fainting, headaches, memory loss, paresthesias, tremor, vertigo and weakness.  
HEMATOLOGIC/LYMPHATIC:  Negative for easy bruising and excessive bleeding.  
PSYCHIATRIC:  Negative for anxiety, crying spells, depression, feelings of stress, anhedonia, mood swings, personality change, premenstrual tension syndrome, difficulty concentrating, recreational drug use, sadness, sleep disturbance and suicidal thoughts.  

Current Problems: 
Essential hypertension 

Allergies: 
Penicillins:
Sulfas:
Naproxen:
Aspirin:
Codeine Sulfate:

Current Medications: 
Avapro 150mg Tablet Take 1 tablet(s) by mouth daily 
Lorazepam 1mg Tablet One tablet one hour prior to flight by mouth 

OBJECTIVE:

Vitals: 

Current: 8/4/2008 2:22:32 PM
Ht: 63.5 inches;  Wt: 150 lbs;  BMI: 26.15
T: 99.1 F (oral);  BP: 135/87 mm Hg (left arm, sitting);  P: 78 bpm (left arm (BP Cuff), sitting);  R: 18 bpm

Exams: 
PHYSICAL EXAM: 
GENERAL: well developed, well nourished;  well groomed;  no apparent distress; 
E/N/T: EARS: external auditory canal normal bilaterally;  bilateral TMs are normal;  OROPHARYNX: posterior pharynx, including tonsils, tongue, and uvula are normal; 
RESPIRATORY: normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs; 
CARDIOVASCULAR: normal rate; rhythm is regular;  normal S1; normal S2; 
MUSCULOSKELETAL: left ankle with moderate swelling and tenderness to palpation of lateral collateral ligaments, full ROM.  Right knee with pain on patella, swelling and effusion under the patella, pain with flexion past 100 degrees.  Full extension and no ligament instability.; 
NEUROLOGIC: mental status: alert and oriented x 3; 
PSYCHIATRIC: appropriate affect and demeanor; normal thought and perception; 

ASSESSMENT: 

845.09	    Ankle sprain, NEC 
924.11	    Contusion of knee 

PLAN: 

 Ankle sprain, NEC *She is put in a gel clamshell on the right knee. *

RADIOLOGY:  I have ordered a left ankle xray to be done today.  
FOLLOW-UP: Schedule a follow-up appointment in 3 weeks.  

  Orders: 
     Left ankle x-ray; 2 views  

 Contusion of knee 

RADIOLOGY:  I have ordered a right knee x-ray to be done today.  

  Orders: 
     Right knee x-ray; three views  


Patient Recommendations:

For  Ankle sprain, NEC: 
left ankle x-ray Schedule a follow-up visit in 3 weeks.  


CHARGE CAPTURE: 

Primary Diagnosis: 
845.09	    Ankle sprain, NEC 

                   Orders:
                    99213  Office/outpatient visit; established patient, level 3  

924.11	    Contusion of knee 


Thanks


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