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cwilson3333

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Am I a 99213-25 or 99214-25

IH: F/u after MRI of left shoulder. The patient's symptoms are about the same. He has pain mainly if he adducts his arm and internally rotates. He has no pain with strain abduction. He has some pain at night and pain with overhead lifting.

PE: ACJ is nontender. Greater tuberosity is nontender. ROM lacks 15 degrees of ER and three ribs on IR. Elevation mild restrictions. Positive impingement test and adduction. Negative Crank. Negative abduction test. Jobe test is weak and painful. Speed test minimal pain. Positive O'Brien test with some weakness. Negative Yergason test.

MRI shows tendinosis and interstitial tearing of SST. Bursitis and ACJ arthritis.

A: Although the ACJ does not appear symptomatic on his exam, this may be contributory. I think the main problem is supraspinatus tendinitis and tendinosis.

P: Discussed the benefits and risk of cortisone injections. I think this is a reasonable thing to try. He should not do any heavy lifting for at least 3 weeks. He should continue with is stretching exercises and light pain-free strengthening. If the subacromial injection of cortisone does not relieve the symptoms, we will probably try to inject the ACJ in about a month.

PROCEDURE: The left shoulder was sterilely prepped. Given 1 cc of cortisone into the subacromial space.

[Remaining documentation in EMR, i.e. current medications, allergies, counseling and education,
which I have not listed here for this thread].

For procedures, I'm thinking 99214-25 and 20610, J1030.
Agree or Disagree

Thank you one and all.
 
cwilson3333 said:
Am I a 99213-25 or 99214-25

IH: F/u after MRI of left shoulder. The patient's symptoms are about the same. He has pain mainly if he adducts his arm and internally rotates. He has no pain with strain abduction. He has some pain at night and pain with overhead lifting.

PE: ACJ is nontender. Greater tuberosity is nontender. ROM lacks 15 degrees of ER and three ribs on IR. Elevation mild restrictions. Positive impingement test and adduction. Negative Crank. Negative abduction test. Jobe test is weak and painful. Speed test minimal pain. Positive O'Brien test with some weakness. Negative Yergason test.

MRI shows tendinosis and interstitial tearing of SST. Bursitis and ACJ arthritis.

A: Although the ACJ does not appear symptomatic on his exam, this may be contributory. I think the main problem is supraspinatus tendinitis and tendinosis.

P: Discussed the benefits and risk of cortisone injections. I think this is a reasonable thing to try. He should not do any heavy lifting for at least 3 weeks. He should continue with is stretching exercises and light pain-free strengthening. If the subacromial injection of cortisone does not relieve the symptoms, we will probably try to inject the ACJ in about a month.

PROCEDURE: The left shoulder was sterilely prepped. Given 1 cc of cortisone into the subacromial space.

[Remaining documentation in EMR, i.e. current medications, allergies, counseling and education,
which I have not listed here for this thread].

For procedures, I'm thinking 99214-25 and 20610, J1030.
Agree or Disagree

Thank you one and all.
Click to expand...

I would report both the 99214-25 20610 and J1030.
 
Shoulder Injection and visit

Thank you "True Blue". That's exactly what I was thinking. I tend to stay away from the 99214 codes, which I know I shouldn't.

Thanks again
 
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