cwilson3333
Expert
Can this visit be billed? Medicare patient in Assisted Living brought to office.
CC: Right wrist fracture
HPI: The patient is 84 year old brought in for evaluation of wrist fx that occurred
5-21-2013. Seen in ER and had CT of CSpine as well as head, which looked okay.
Facility she is at reports she has not been able to keep splint or wrap on hand and
she messes with whatever is put on and tries to get it off. Has a bulky dressing on
today.
PE: General appearance; WDWN femal in no acute distress
Musculoskeletal: She does not want to be examined; refuses to remove Ace wrap.
Very upset and wants to leave office. The aide who brought her in says she has not
been like this in past. I [the physican asst] contacted son and daugher by phone.
Daughter said she was like this when they took her to hospital.
Orders: Xrays of LS showed some degenerative changes and spondylolisthesis.
Xrays of wrist show comminuted intraarticular fx of distal radius and ulnar
styloid.
Assessment: Comminuted intraarticular fx distal radius and ulnar styloid.
Plan: We went over tx options, including conservative care and the fact that there would
be a clinical deformity, loss of ROM vs rights of surgery or closed reduction. She
[the aide] will discuss with the brother [who is physician] and figure out what they
want to do. If they would like her seen, we would be happy to see her back.
The aide was given a Velcro spint to try on her.
Again, no examination was done.
Signature of physician assistant
CC: Right wrist fracture
HPI: The patient is 84 year old brought in for evaluation of wrist fx that occurred
5-21-2013. Seen in ER and had CT of CSpine as well as head, which looked okay.
Facility she is at reports she has not been able to keep splint or wrap on hand and
she messes with whatever is put on and tries to get it off. Has a bulky dressing on
today.
PE: General appearance; WDWN femal in no acute distress
Musculoskeletal: She does not want to be examined; refuses to remove Ace wrap.
Very upset and wants to leave office. The aide who brought her in says she has not
been like this in past. I [the physican asst] contacted son and daugher by phone.
Daughter said she was like this when they took her to hospital.
Orders: Xrays of LS showed some degenerative changes and spondylolisthesis.
Xrays of wrist show comminuted intraarticular fx of distal radius and ulnar
styloid.
Assessment: Comminuted intraarticular fx distal radius and ulnar styloid.
Plan: We went over tx options, including conservative care and the fact that there would
be a clinical deformity, loss of ROM vs rights of surgery or closed reduction. She
[the aide] will discuss with the brother [who is physician] and figure out what they
want to do. If they would like her seen, we would be happy to see her back.
The aide was given a Velcro spint to try on her.
Again, no examination was done.
Signature of physician assistant