Wiki Pain Management

TLGray

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We are having a lot of issues with our Pain Management. A patient comes in for pain management due to back, hip and leg pain due to sacroiliitis, lumbar degenerative disc disease, lumbar radiculopathy, lumbar spondylosis.

The following dx are under Impression and Recommendations:

Problem # 1: MYOFASCIAL PAIN (ICD-729.1) (ICD10-M79.1)
Assessment: Unchanged

Orders:
99214 Detailed Est (CPT-99214)


Problem # 2: SACROILIITIS (ICD-720.2) (ICD10-M46.1)
Assessment: Unchanged

Orders:
99214 Detailed Est (CPT-99214)


Problem # 3: LUMBAR SPINAL STENOSIS (ICD-724.02) (ICD10-M48.06)
Assessment: Unchanged

Orders:
99214 Detailed Est (CPT-99214)


Problem # 4: LUMBAR RADICULOPATHY (ICD-724.4) (ICD10-M54.16)
Assessment: Unchanged

His updated medication list for this problem includes:
Norco 7.5-325 Mg Oral Tablet (Hydrocodone-acetaminophen) ..... 1 tablet twice to three times daily

Orders:
99214 Detailed Est (CPT-99214)


Problem # 5: LUMBAR SPONDYLOSIS (ICD-721.3) (ICD10-M47.896)
Assessment: Unchanged

Orders:
99214 Detailed Est (CPT-99214)


Problem # 6: LUMBAR POSTLAMINECTOMY SYNDROME (ICD-722.83) (ICD10-M96.1)
Assessment: Unchanged

Orders:
99214 Detailed Est (CPT-99214)

Can someone tell me which diagnosis to use there is some discrepancy in our office how to code this.

Thanks
 
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