Wiki Doc wants 99215 for this? High MDM?

[Orthocoderpgu]

Patient comes in today for follow-up for his left knee. He has a very complicated history here, including a previous total knee, quad tendon rupture repair, and then revision of that repair. Overall, he states he feels like the tendon is doing well. He can actively walk, straighten his leg, and extend his leg from a flexed position, but he's having a fairly significant amount of swelling in his knee and pain in the back of his knee. He states he did see Dr. McCandless on my recommendation previously and was told that the poly looked pretty good on an x-ray.On examination, he has some generalized swelling in the soft tissues anteriorly, medially, and laterally. He has no significant joint effusion. He has a palpable what feels like Baker's cyst posteriorly, which is very tense and sore for him. He has full extension and his flexion was to about 120 degrees, limited by pain. He can actively extend his leg from a flexed position and do a straight leg raise. There is a palpable defect in the patella, but this is covered with graft, which
is also palpable.

X-ray Examination: Two views of the left knee show the total knee to be in place. The cerclage wire of the patella is broken, as has been mentioned before, and there is some diastasis of the patella. There appears to be a loose bony fragment in the posterior knee with a surrounding large cystic fluid. There appears to be some osteolysis around his tibial implant.

Assessment: Status post above-mentioned procedures.

Plan: I discussed with patient that I think at this point, I'm a little bit concerned about his

poly wear and that he's getting some particle debris leading to some inflammation and some secondary osteolysis. In light of this, I recommended he go back and see Dr. X and

discuss this, but I also recommended an ultrasound-guided aspiration of the cyst behind his knee to see if we can't help with his pain. I wrote him for some Naprosyn to help with some of the discomfort he's having currently. We'll see him back following his discussion with Dr. X

ADC/rrr
Assessment/ Plan
Disorder of bone and cartilage, unspecified (733.90)

(LOOK AT THIS FROM MDM ONLY)

 

[OCD_coder]

There is no time documentation to support a 99215.

There is not a high risk to the patient, I did not see a discussion for surgery with identified risks. I get a moderate Risk with an existing problem worsening, no additional workup ordered for the complexity of data and this isn't a life threatening condition - which would not support a high MDM.