arkolab
Contributor
Does this encounter support billing a 99214 with the injection?
HPI: PT is a 54 year old female with a chief complaint of right lateral elbow pain. The symptoms have been going on for 6 months. Evaluation to date has included visit with PCP. Treatment to date has included therapy exercises. The symptoms are improved by rest and exacerbated by elbow and wrist motion and use. The current symptoms are rated moderate. Denies numbness/tingling.
she reports that she has never smoked. She has never been exposed to tobacco smoke. She has never used smokeless tobacco.
PSH:
Past Surgical History:
Procedure Laterality Date
• Breast Biopsy
• BREAST BIOPSY, EXCISION Left 2016
(-)
• Cervix Procedure/Surgery 10/01/1989
cautery
• Cesarean Section 06/17/1995
• Cesarean Section 12/24/2001
• Cholecystectomy 12/02/2005
• Knee Arthroscopy Right 07/19/2010
• OOPHORECTOMY 06/01/1988
• PR REMOVAL OF OVARY(S) Right 1988
• SINUS SURGERY N/A 07/19/2023
N/A; Functional endoscopic sinus surgery, bilateral frontal and sphenoid dilation, bilateral maxillary antrostomy, possible bilateral total ethmoidectomy , bilateral submucosal resection of inferior turbinate, sinus navigation, post operative debridement
• Skin Lesion Excision, Malignant
right popliteal- in situ
• Wisdom Tooth Extraction
Reviewed by MD on 12/23/2024
SOCIAL HISTORY:
Social History
Occupational History
• Not on file
Tobacco Use
• Smoking status: Never
Passive exposure: Never
• Smokeless tobacco: Never
Vaping Use
• Vaping status: Never Used
Substance and Sexual Activity
• Alcohol use: Yes
Comment: occasional
• Drug use: Never
• Sexual activity: Yes
Partners: Male
Birth control/protection: None
Reviewed by MD on 12/23/2024
PMH:
Patient Active Problem List
Diagnosis Date Noted
• Pelvic floor tension 03/13/2024
Priority: Not Prioritized
• Vertigo 05/05/2023
Priority: Not Prioritized
• Asthma (HCC) 12/15/2021
Priority: Not Prioritized
Formatting of this note might be different from the original.
(Abstracted records from Medical Associates Clinic Care Everywhere)
• Hyperlipidemia 12/15/2021
Priority: Not Prioritized
Formatting of this note might be different from the original.
(Abstracted records from Medical Associates Clinic Care Everywhere)
• Rectocele 06/07/2021
Priority: Not Prioritized
• Vaginal vault prolapse 05/04/2021
Priority: Not Prioritized
• Urinary incontinence 05/04/2021
Priority: Not Prioritized
• Depression 02/27/2020
Priority: Not Prioritized
• History of melanoma in situ 02/27/2020
Priority: Not Prioritized
• Abnormal mammogram 02/13/2014
Priority: Not Prioritized
• Vasomotor rhinitis 06/27/2023
• PND (post-nasal drip) 06/27/2023
• Nasal congestion 06/27/2023
• Allergic rhinitis 06/27/2023
• Endometriosis 10/04/2017
Past Medical History:
Diagnosis Date
• Abnormal mammogram
• Anemia
• Depressed
was on wellbutrin- tinnitus
• Endometriosis
• Menopause
age 52
Reviewed by MD on 12/23/2024
MEDICATIONS:
Current Outpatient Medications
Medication
• amitriptyline (Elavil) 25 MG tablet
• budesonide (Pulmicort) 0.5 MG/2ML nebulizer suspension
• cetirizine (ZYRTEC ALLERGY) 10 MG gel capsule
• diclofenac sodium EC (Voltaren) 75 MG tablet
• fluticasone hfa 110 (Flovent HFA 110) 110 MCG/ACT inhaler
• montelukast (Singulair) 10 MG tablet
• olopatadine (Pataday) 0.2 % ophthalmic solution
• Other
• Ventolin HFA 108 (90 Base) MCG/ACT inhaler
No current facility-administered medications for this visit.
Reviewed by MD on 12/23/2024
ALLERGIES:
Allergies
Allergen Reactions
• Codeine Urticaria
• Sulfamethoxazole W-Trimethoprim Rash
• Bupropion Tinnitus
Reviewed by MD on 12/23/2024
FAMILY HISTORY:
Family History
Problem Relation Name Age of Onset
• Hyperlipidemia Mother
• Hypertension Mother
• Parkinson's Disease Mother
• Hypertension Father
• Hyperlipidemia Father
• Cancer - Bladder Brother
• Hypertension Brother
• CVA Brother
• Lupus Sister
• Cancer - Breast Maternal Grandmother
dx 80s
• Cancer - Breast Maternal Aunt
• Cancer - Breast Cousin
Reviewed by MD on 12/23/2024
ROS:
GENERAL: Negative for malaise, significant weight loss, fever/chills
HEENT: No changes in hearing or vision
RESPIRATORY: Negative for cough or wheezing
CARDIOVASCULAR: Negative for chest pain or palpitations
GASTROINTESTINAL: No change in bowel habits
GENITOURINARY: Negative for change in urinary habits
NEUROLOGIC: Negative for dizziness or syncope
SKIN: Negative for skin changes
PSYCHIATRIC: Negative for recent psychosocial stressors
HEMATOLOGIC/LYMPHATIC: Negative for lymphadenopathy
PHYSICAL EXAMINATION:
Vitals: BP 116/70 | Pulse 68 | SpO2 98%
General: Patient is a healthy appearing female. No acute distress.
Psych: Affect normal. Conjugate gaze.
Eyes: Sclera clear. Tracks appropriately
ENMT: Ears and nose atraumatic. No rhinorrhea.
Cardiac: Regular rate by peripheral pulse palpation. Regular rhythm.
Respiratory: Unlabored on room air. No audible wheezing.
Lymphatic: No palpable lymphadenopathy. No lymphedema.
Skin: No rashes, lesions, or induration by inspection or palpation.
Neck: Full ROM. No radicular symptoms.
RUE:
Elbow with minimal stiffness in flexion and extension arc. No open wounds. Severe tenderness to palpation lateral epicondyle. There is pain with resisted wrist and long finger extension. No deformity present. Sensation intact to light touch in the ulnar nerve distribution. Equal and intact sensation radial 3 digits.
IMAGING:
I independently reviewed, interpreted, and discussed with the patient their recent imaging, including XR completed at SWHC in 2024 which demonstrates no abnormality. Please see full radiology report for further details and radiologist interpretation.
LABS, TESTS, DIAGNOSTICS, & RECORD REVIEW: I independently reviewed documentation and records from the patient's recent visit with family med provider, PA-C
ASSESSMENT: Right lateral epicondylitis (primary encounter diagnosis)
PLAN: I discussed with patient the diagnosis and my impression, its etiology, and different treatment options. We discussed the risks and benefits of the different management options. We discussed risk reduction and prognosis. We had a long discussion regarding the etiology and treatment options for epicondylosis of the elbow. We discussed injection options and their risks, OT, ultrasound-guided percutaneous tenotomy (TenJet), surgery options, and the risks of each. We discussed the surgery option of common extensor tenotomy, debridement, repair, partial ostectomy, arthrotomy with synovectomy as well as the high morbidity nature of this surgery and the risks involved to the joint, bone, and tendon. After discussing this in detail, the patient elects for injection which is provided. She will also commence therapy. She will keep me posted on response and next steps. We discussed management specifics and timing and follow-up. she is pleased for the education and care and in full agreement with the plan.
The risk, benefits, and alternatives of injection and no injection therapy were discussed, including the risk of infection, bleeding, failure to improve, hypopigmentation, fat atrophy, tendon rupture, and blood glucose elevations seen with diabetes. The patient verbally consented for an injection and a timeout was done to confirm patient name, birthdate, and injection site. The injection site was prepped with a alcohol swab. The right elbow lateral epicondyle was palpated with a 25G needle and injected with Kenlog (60mg), and 2mL xylocaine plain 2%. The lateral epicondyle and anterior sulcus were needled followed by the common extensor tendon distally down the path of ECRB for 2cm. The injection site was then dressed with a bandaid. The patient tolerated the injection well. The patient was instructed to call the office if any adverse local effects occurred or any if any questions or concerns arise.
HPI: PT is a 54 year old female with a chief complaint of right lateral elbow pain. The symptoms have been going on for 6 months. Evaluation to date has included visit with PCP. Treatment to date has included therapy exercises. The symptoms are improved by rest and exacerbated by elbow and wrist motion and use. The current symptoms are rated moderate. Denies numbness/tingling.
she reports that she has never smoked. She has never been exposed to tobacco smoke. She has never used smokeless tobacco.
PSH:
Past Surgical History:
Procedure Laterality Date
• Breast Biopsy
• BREAST BIOPSY, EXCISION Left 2016
(-)
• Cervix Procedure/Surgery 10/01/1989
cautery
• Cesarean Section 06/17/1995
• Cesarean Section 12/24/2001
• Cholecystectomy 12/02/2005
• Knee Arthroscopy Right 07/19/2010
• OOPHORECTOMY 06/01/1988
• PR REMOVAL OF OVARY(S) Right 1988
• SINUS SURGERY N/A 07/19/2023
N/A; Functional endoscopic sinus surgery, bilateral frontal and sphenoid dilation, bilateral maxillary antrostomy, possible bilateral total ethmoidectomy , bilateral submucosal resection of inferior turbinate, sinus navigation, post operative debridement
• Skin Lesion Excision, Malignant
right popliteal- in situ
• Wisdom Tooth Extraction
Reviewed by MD on 12/23/2024
SOCIAL HISTORY:
Social History
Occupational History
• Not on file
Tobacco Use
• Smoking status: Never
Passive exposure: Never
• Smokeless tobacco: Never
Vaping Use
• Vaping status: Never Used
Substance and Sexual Activity
• Alcohol use: Yes
Comment: occasional
• Drug use: Never
• Sexual activity: Yes
Partners: Male
Birth control/protection: None
Reviewed by MD on 12/23/2024
PMH:
Patient Active Problem List
Diagnosis Date Noted
• Pelvic floor tension 03/13/2024
Priority: Not Prioritized
• Vertigo 05/05/2023
Priority: Not Prioritized
• Asthma (HCC) 12/15/2021
Priority: Not Prioritized
Formatting of this note might be different from the original.
(Abstracted records from Medical Associates Clinic Care Everywhere)
• Hyperlipidemia 12/15/2021
Priority: Not Prioritized
Formatting of this note might be different from the original.
(Abstracted records from Medical Associates Clinic Care Everywhere)
• Rectocele 06/07/2021
Priority: Not Prioritized
• Vaginal vault prolapse 05/04/2021
Priority: Not Prioritized
• Urinary incontinence 05/04/2021
Priority: Not Prioritized
• Depression 02/27/2020
Priority: Not Prioritized
• History of melanoma in situ 02/27/2020
Priority: Not Prioritized
• Abnormal mammogram 02/13/2014
Priority: Not Prioritized
• Vasomotor rhinitis 06/27/2023
• PND (post-nasal drip) 06/27/2023
• Nasal congestion 06/27/2023
• Allergic rhinitis 06/27/2023
• Endometriosis 10/04/2017
Past Medical History:
Diagnosis Date
• Abnormal mammogram
• Anemia
• Depressed
was on wellbutrin- tinnitus
• Endometriosis
• Menopause
age 52
Reviewed by MD on 12/23/2024
MEDICATIONS:
Current Outpatient Medications
Medication
• amitriptyline (Elavil) 25 MG tablet
• budesonide (Pulmicort) 0.5 MG/2ML nebulizer suspension
• cetirizine (ZYRTEC ALLERGY) 10 MG gel capsule
• diclofenac sodium EC (Voltaren) 75 MG tablet
• fluticasone hfa 110 (Flovent HFA 110) 110 MCG/ACT inhaler
• montelukast (Singulair) 10 MG tablet
• olopatadine (Pataday) 0.2 % ophthalmic solution
• Other
• Ventolin HFA 108 (90 Base) MCG/ACT inhaler
No current facility-administered medications for this visit.
Reviewed by MD on 12/23/2024
ALLERGIES:
Allergies
Allergen Reactions
• Codeine Urticaria
• Sulfamethoxazole W-Trimethoprim Rash
• Bupropion Tinnitus
Reviewed by MD on 12/23/2024
FAMILY HISTORY:
Family History
Problem Relation Name Age of Onset
• Hyperlipidemia Mother
• Hypertension Mother
• Parkinson's Disease Mother
• Hypertension Father
• Hyperlipidemia Father
• Cancer - Bladder Brother
• Hypertension Brother
• CVA Brother
• Lupus Sister
• Cancer - Breast Maternal Grandmother
dx 80s
• Cancer - Breast Maternal Aunt
• Cancer - Breast Cousin
Reviewed by MD on 12/23/2024
ROS:
GENERAL: Negative for malaise, significant weight loss, fever/chills
HEENT: No changes in hearing or vision
RESPIRATORY: Negative for cough or wheezing
CARDIOVASCULAR: Negative for chest pain or palpitations
GASTROINTESTINAL: No change in bowel habits
GENITOURINARY: Negative for change in urinary habits
NEUROLOGIC: Negative for dizziness or syncope
SKIN: Negative for skin changes
PSYCHIATRIC: Negative for recent psychosocial stressors
HEMATOLOGIC/LYMPHATIC: Negative for lymphadenopathy
PHYSICAL EXAMINATION:
Vitals: BP 116/70 | Pulse 68 | SpO2 98%
General: Patient is a healthy appearing female. No acute distress.
Psych: Affect normal. Conjugate gaze.
Eyes: Sclera clear. Tracks appropriately
ENMT: Ears and nose atraumatic. No rhinorrhea.
Cardiac: Regular rate by peripheral pulse palpation. Regular rhythm.
Respiratory: Unlabored on room air. No audible wheezing.
Lymphatic: No palpable lymphadenopathy. No lymphedema.
Skin: No rashes, lesions, or induration by inspection or palpation.
Neck: Full ROM. No radicular symptoms.
RUE:
Elbow with minimal stiffness in flexion and extension arc. No open wounds. Severe tenderness to palpation lateral epicondyle. There is pain with resisted wrist and long finger extension. No deformity present. Sensation intact to light touch in the ulnar nerve distribution. Equal and intact sensation radial 3 digits.
IMAGING:
I independently reviewed, interpreted, and discussed with the patient their recent imaging, including XR completed at SWHC in 2024 which demonstrates no abnormality. Please see full radiology report for further details and radiologist interpretation.
LABS, TESTS, DIAGNOSTICS, & RECORD REVIEW: I independently reviewed documentation and records from the patient's recent visit with family med provider, PA-C
ASSESSMENT: Right lateral epicondylitis (primary encounter diagnosis)
PLAN: I discussed with patient the diagnosis and my impression, its etiology, and different treatment options. We discussed the risks and benefits of the different management options. We discussed risk reduction and prognosis. We had a long discussion regarding the etiology and treatment options for epicondylosis of the elbow. We discussed injection options and their risks, OT, ultrasound-guided percutaneous tenotomy (TenJet), surgery options, and the risks of each. We discussed the surgery option of common extensor tenotomy, debridement, repair, partial ostectomy, arthrotomy with synovectomy as well as the high morbidity nature of this surgery and the risks involved to the joint, bone, and tendon. After discussing this in detail, the patient elects for injection which is provided. She will also commence therapy. She will keep me posted on response and next steps. We discussed management specifics and timing and follow-up. she is pleased for the education and care and in full agreement with the plan.
The risk, benefits, and alternatives of injection and no injection therapy were discussed, including the risk of infection, bleeding, failure to improve, hypopigmentation, fat atrophy, tendon rupture, and blood glucose elevations seen with diabetes. The patient verbally consented for an injection and a timeout was done to confirm patient name, birthdate, and injection site. The injection site was prepped with a alcohol swab. The right elbow lateral epicondyle was palpated with a 25G needle and injected with Kenlog (60mg), and 2mL xylocaine plain 2%. The lateral epicondyle and anterior sulcus were needled followed by the common extensor tendon distally down the path of ECRB for 2cm. The injection site was then dressed with a bandaid. The patient tolerated the injection well. The patient was instructed to call the office if any adverse local effects occurred or any if any questions or concerns arise.