Wiki Help! Em level

[selsal]

ESTABLISHED PT

EPF HISTORY
DETAILED PE

RIGHT HAND SIGNIFICANT PAIN, LEFT HAND MINIMAL. TESTING CONCLUDES LEFT HAND CTS BUT NOT IN RIGHT.
PLAN -Discussed prognosis of carpal tunnel syndrome.

-Discussed referral to physical therapy for her hand symptoms.

-Discussed referral to hand surgery.

ANY THOUGHTS GREATLY APPRECIATED!

 

[LindaEV]

Pt has CTS, seems like a new problem. The note says "discussed" options of therapy and surgery, but I don't know whether it was actually ordered on not. based on what is there I would go with a 99213.