twosmek
Guest
I have to code for a patient that is referred to us because of walking on his toes. This is the dictation from the MD.
HISTORY OF PRESENT ILLNESS:
This is a 7-year-old who is here for assessment of toe walking. He has been previously seen by Dr. ___ at ______ location here in _____ and has also been seen by neurology for problems with toe walking and mild behavioral changes, developmental delay suggestive of autism. He receive services at school including daily stretching. Regarding his toe walking, he has been a habitual toe walker all his life. He has no clonus, no associated spasticity. He has had macrocephaly but no known impairments associated with that today. His head seems to be fairly proportional. He is fairly communicative today, is pleasant, approachable, does make eye contact and he smiles. He cooperates. He will come down on his heels when cued but has to hyperextend his knees because he has pretty much lost all functional dorsiflexion. He wears boot apparently to hide his tendency to walk on his toes. so he is wearing Wellington type boots today with his feet plantarflexed inside of them. He does not have any skin lesions on his feet. His heels looks small, but I think it is mostly because he just walks on his toes. The therapist was apparently concerned that his arches were going flat; however, he has good arches today. His foot x-rays are normal except for his plantar flexed posture.
His past medical, social, family history and a very thorough exam by Dr. ____ are available on the chart.
Recommendation in the past was to have posterior leaf spring SMOs which are lower extremity braces. I would call them AFOs but anyway, this was not done. I spoke to mom about it and she was very whishy washy and just not sure. She did not seem to understand the urgency. I believe that since she did not act on this he has lost dorsiflexion he did have. In a seated position he has about -5-10 of dorsiflexion at maximum stretch, with the knee extended, he has -10 of dorsiflexion with the knee flexed, he has about neutral dorsiflexion. He does not have excessive popliteal angles but he does definitely walk on his toes. He was able to barely walk on his heels for me requiring a significant posture compensation.
I explained to mom that something needs to be done about this or it will continue to progress, he may be to the point where he requires surgery though a trial of casting and/or AFOs might be warranted. I would think casting for awhile, followed by AFOs would certainly be a possibility for him. I think, however, given his failure to respond to the stretching and interventions that he has had so far and his coordinating his ability diagnoses, I think it would probably be helpful for him to be working through a comprehensive pediatric orthopedic clinic and I will check with a couple options in order to get him an appropriate referral. We will have to contact the mom about those details once that is arranged.
ASSESSMENT AND PLAN:
Habitual toe walking becoming tight Achilles with very limited to nonexistent dorsiflexion definitely progressive worsening of the problem from the records that I have. He definitely needs some intervention on this, but I think he should be evaluated by a pediatric orthopedist for more efficient suggestions and experienced recommendations. We will help to arrange referral for him.
How would you code it. I was thinking that I could use 307.9 which states: "other and unspecified special symptoms or syndromes, not elsewhere classified" and it has the following listed under it to include--hair plucking, lisping, masterbation, nail-biting, thum-sucking. So I was thinking that it fits right??
HISTORY OF PRESENT ILLNESS:
This is a 7-year-old who is here for assessment of toe walking. He has been previously seen by Dr. ___ at ______ location here in _____ and has also been seen by neurology for problems with toe walking and mild behavioral changes, developmental delay suggestive of autism. He receive services at school including daily stretching. Regarding his toe walking, he has been a habitual toe walker all his life. He has no clonus, no associated spasticity. He has had macrocephaly but no known impairments associated with that today. His head seems to be fairly proportional. He is fairly communicative today, is pleasant, approachable, does make eye contact and he smiles. He cooperates. He will come down on his heels when cued but has to hyperextend his knees because he has pretty much lost all functional dorsiflexion. He wears boot apparently to hide his tendency to walk on his toes. so he is wearing Wellington type boots today with his feet plantarflexed inside of them. He does not have any skin lesions on his feet. His heels looks small, but I think it is mostly because he just walks on his toes. The therapist was apparently concerned that his arches were going flat; however, he has good arches today. His foot x-rays are normal except for his plantar flexed posture.
His past medical, social, family history and a very thorough exam by Dr. ____ are available on the chart.
Recommendation in the past was to have posterior leaf spring SMOs which are lower extremity braces. I would call them AFOs but anyway, this was not done. I spoke to mom about it and she was very whishy washy and just not sure. She did not seem to understand the urgency. I believe that since she did not act on this he has lost dorsiflexion he did have. In a seated position he has about -5-10 of dorsiflexion at maximum stretch, with the knee extended, he has -10 of dorsiflexion with the knee flexed, he has about neutral dorsiflexion. He does not have excessive popliteal angles but he does definitely walk on his toes. He was able to barely walk on his heels for me requiring a significant posture compensation.
I explained to mom that something needs to be done about this or it will continue to progress, he may be to the point where he requires surgery though a trial of casting and/or AFOs might be warranted. I would think casting for awhile, followed by AFOs would certainly be a possibility for him. I think, however, given his failure to respond to the stretching and interventions that he has had so far and his coordinating his ability diagnoses, I think it would probably be helpful for him to be working through a comprehensive pediatric orthopedic clinic and I will check with a couple options in order to get him an appropriate referral. We will have to contact the mom about those details once that is arranged.
ASSESSMENT AND PLAN:
Habitual toe walking becoming tight Achilles with very limited to nonexistent dorsiflexion definitely progressive worsening of the problem from the records that I have. He definitely needs some intervention on this, but I think he should be evaluated by a pediatric orthopedist for more efficient suggestions and experienced recommendations. We will help to arrange referral for him.
How would you code it. I was thinking that I could use 307.9 which states: "other and unspecified special symptoms or syndromes, not elsewhere classified" and it has the following listed under it to include--hair plucking, lisping, masterbation, nail-biting, thum-sucking. So I was thinking that it fits right??
