trose45116
Expert
E/M can be so confusing. I came from just coding surgeries and trying to understand E/M is so confusing. I know the modifier 25 will be applied but since they are going to get her into pt and reviewed the MRI would this be enough to bill the OV?? Anyone have any examples of when an office visit can be billed with the minor procedure??
Right shoulder.
HPI:
Appointment type:
Established patient - Established problem Patient returns for her right shoulder. She denies any other complaints She continues to be symptomatically. She did obtain an MRI. She comes in today to review the results.
ROS:
Unchanged from 12/9/2015.
Surgical History: hysterectomy, rt ankle, lt knee .
Family History:
arthritis, diabetes, stroke.
Social History:
tobacco- no
alcohol- no
single.
Medications: Taking Medrol (Pak) 4 MG Tablet as directed as directed
Allergies: N.K.D.A.
Objective:
Vitals: Wt 130 lbs, BMI 21.63 Index, Ht 65 in.
Examination:
General Examination:
GENERAL APPEARANCE: in no acute distress, well developed, well nourished.
EXTREMITIES: Exam of cervical spine, No tenderness to palpation of spinous processes. Normal ROM of cervical spine. No trapezial muscle spasm noted.Examination of right shoulder. No skin abnormalities. No masses. No obvious muscle atrophy noted in suprascapular fossae. No scapular winging noted. No specific periscapular tenderness to palpation. No AC joint tenderness noted. No SC joint tenderness elicited. Pain with palpation about the rotator cuff. No pain with palpation about the proximal biceps. Positve hawkins and neers test.Pain with Jobes testing. Weakness noted.Full active and passive shoulder ROM.Negative apprehesion, yergasons, speeds, belly press, lift off, bear hug, Pain with cross body adduction.Normal sensation to light touch throught entire left uppper extremity.Biceps, brachioradialis, triceps refelexes normal.Radial pulse 2+. Good capillary refill.5/5 motors with deltoid, biceps,triceps, BR, finger flexors, finger extensors, writst flexors, and wrist extensors.Examination of the opposite shoulder is within normal limits for ROM, motors, sensation, pulses and skin..
Assessment:
Assessment:
1. Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic - M75.111 (Primary)
Plan:
1. Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic
Notes: MRI of the right shoulder was reviewed. She does have evidence of a partial-thickness tear about the supraspinatus. This is articular based. Glenohumeral joint is well maintained subdeltoid bursitis. Subscapularis intact. Biceps intact. No labral tear.
At this point I did describe starting with a steroid injection. She was in agreement. She was taken to the procedure room. Under ultrasound guidance. 2 cc of Kenalog and 4 cc Marcaine was injected in the subacromial space. Patient tolerated this well. We will get her going in physical therapy. All questions were answered. If she does poorly. She would be a candidate for arthroscopic surgery.
Procedure Codes: 20611 INJECTION JOINT/BURSA/DRAIN W/US, J3301 Inj, triamcinolone acetonide 80mg
Follow Up: prn
Right shoulder.
HPI:
Appointment type:
Established patient - Established problem Patient returns for her right shoulder. She denies any other complaints She continues to be symptomatically. She did obtain an MRI. She comes in today to review the results.
ROS:
Unchanged from 12/9/2015.
Surgical History: hysterectomy, rt ankle, lt knee .
Family History:
arthritis, diabetes, stroke.
Social History:
tobacco- no
alcohol- no
single.
Medications: Taking Medrol (Pak) 4 MG Tablet as directed as directed
Allergies: N.K.D.A.
Objective:
Vitals: Wt 130 lbs, BMI 21.63 Index, Ht 65 in.
Examination:
General Examination:
GENERAL APPEARANCE: in no acute distress, well developed, well nourished.
EXTREMITIES: Exam of cervical spine, No tenderness to palpation of spinous processes. Normal ROM of cervical spine. No trapezial muscle spasm noted.Examination of right shoulder. No skin abnormalities. No masses. No obvious muscle atrophy noted in suprascapular fossae. No scapular winging noted. No specific periscapular tenderness to palpation. No AC joint tenderness noted. No SC joint tenderness elicited. Pain with palpation about the rotator cuff. No pain with palpation about the proximal biceps. Positve hawkins and neers test.Pain with Jobes testing. Weakness noted.Full active and passive shoulder ROM.Negative apprehesion, yergasons, speeds, belly press, lift off, bear hug, Pain with cross body adduction.Normal sensation to light touch throught entire left uppper extremity.Biceps, brachioradialis, triceps refelexes normal.Radial pulse 2+. Good capillary refill.5/5 motors with deltoid, biceps,triceps, BR, finger flexors, finger extensors, writst flexors, and wrist extensors.Examination of the opposite shoulder is within normal limits for ROM, motors, sensation, pulses and skin..
Assessment:
Assessment:
1. Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic - M75.111 (Primary)
Plan:
1. Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic
Notes: MRI of the right shoulder was reviewed. She does have evidence of a partial-thickness tear about the supraspinatus. This is articular based. Glenohumeral joint is well maintained subdeltoid bursitis. Subscapularis intact. Biceps intact. No labral tear.
At this point I did describe starting with a steroid injection. She was in agreement. She was taken to the procedure room. Under ultrasound guidance. 2 cc of Kenalog and 4 cc Marcaine was injected in the subacromial space. Patient tolerated this well. We will get her going in physical therapy. All questions were answered. If she does poorly. She would be a candidate for arthroscopic surgery.
Procedure Codes: 20611 INJECTION JOINT/BURSA/DRAIN W/US, J3301 Inj, triamcinolone acetonide 80mg
Follow Up: prn