trose45116
Expert
I don't think we can code for the office visit...what are your thoughts???
Chief Complaints:
1. Right knee pain.
HPI:
Appointment type:
Established patient - Established problem Patient returns for her right knee. She continues to be symptomatic. She denies any other specific complaints. .
ROS:
no change from 1-8-16.
Surgical History: foot, c section .
Family History: Non-Contributory
Social History:
tobacco- no
alcohol- yes
married.
Medications: Taking Duloxetine HCl , Discontinued Medrol (Pak) 4 MG Tablet as directed as directed, Medication List reviewed and reconciled with the patient
Allergies: Sulfa.
Objective:
Vitals: Wt 155 lbs, BMI 26.60 Index, Ht 5 ft 4 in.
Examination:
Right knee:
LEG EXAMINATION: Alert and oriented times three, NAD with a normal affect. Exam of the right knee reveals normal alignment. Mild effusion. Good patellar mobility. TTP over medial joint line. No lateral joint line tenderness. ROM is full with pain in deep flexion. The knee is stable to ligamentous exam. Positive McMurray's. 5/5 MMT with quadriceps and hamstrings. Posterolateral corner intact. Pain to palpation anterolaterally just distal to the knee joint Sensation intact, distal pulse 2+. Negative calf tenderness, negative Homan's.Exam of the left knee reveals noraml alignment. Full AROM and strength. Knee is stable to exam. Negative calf tenderness, negative Homan's. Sensation intact, distal pulse 2+..
Assessment:
Assessment:
1. Acute pain of right knee - M25.561 (Primary)
Plan:
1. Acute pain of right knee
Notes: I'll long discussion with the patient. I did describe doing a steroid injection anterolaterally. I would needle this area as well. She was in agreement. 1 cc Kenalog and 1 cc Marcaine was injected under ultrasound guidance. Patient tolerated this well. All questions were answered. We will get her going in physical therapy.
Procedure Codes: 20611 INJECTION JOINT/BURSA/DRAIN W/US, J3301 Inj, triamcinolone acetonide, 40mg
Follow Up: 6 Weeks
Chief Complaints:
1. Right knee pain.
HPI:
Appointment type:
Established patient - Established problem Patient returns for her right knee. She continues to be symptomatic. She denies any other specific complaints. .
ROS:
no change from 1-8-16.
Surgical History: foot, c section .
Family History: Non-Contributory
Social History:
tobacco- no
alcohol- yes
married.
Medications: Taking Duloxetine HCl , Discontinued Medrol (Pak) 4 MG Tablet as directed as directed, Medication List reviewed and reconciled with the patient
Allergies: Sulfa.
Objective:
Vitals: Wt 155 lbs, BMI 26.60 Index, Ht 5 ft 4 in.
Examination:
Right knee:
LEG EXAMINATION: Alert and oriented times three, NAD with a normal affect. Exam of the right knee reveals normal alignment. Mild effusion. Good patellar mobility. TTP over medial joint line. No lateral joint line tenderness. ROM is full with pain in deep flexion. The knee is stable to ligamentous exam. Positive McMurray's. 5/5 MMT with quadriceps and hamstrings. Posterolateral corner intact. Pain to palpation anterolaterally just distal to the knee joint Sensation intact, distal pulse 2+. Negative calf tenderness, negative Homan's.Exam of the left knee reveals noraml alignment. Full AROM and strength. Knee is stable to exam. Negative calf tenderness, negative Homan's. Sensation intact, distal pulse 2+..
Assessment:
Assessment:
1. Acute pain of right knee - M25.561 (Primary)
Plan:
1. Acute pain of right knee
Notes: I'll long discussion with the patient. I did describe doing a steroid injection anterolaterally. I would needle this area as well. She was in agreement. 1 cc Kenalog and 1 cc Marcaine was injected under ultrasound guidance. Patient tolerated this well. All questions were answered. We will get her going in physical therapy.
Procedure Codes: 20611 INJECTION JOINT/BURSA/DRAIN W/US, J3301 Inj, triamcinolone acetonide, 40mg
Follow Up: 6 Weeks