rjenn86
Guru
I'm needing help regarding an ill fitting prosthesis for ICD9 code? Would I use 996.40??.....Here is the dictation, Thank you :
Patient presents to the office today with a complaint of an ill fitting the right leg prosthesis status post right below the knee amputation in 2007. he states that he has had no adjustments to his prosthesis since she was discharged from the hospital following his amputation in 2007. He has gained significant weight since that time and is having an area of redness on his stump that he and his wife are concerned about. He is here today for further evaluation.
PHYSICAL EXAMINATION:
Patient is alert and oriented x3. He is in no acute distress. Moderately obese. His right leg demonstrates a below the knee amputation with prosthesis currently fitted. Skin is intact.
ASSESSMENT:
Ill fitting prosthesis status post right below the knee amputation
PLAN:
Patient is advised that we do not deal with fitting of prostheses, and I have referred him to Evergreen prosthetics and orthotics. A prescription is sent to Evergreen for repair of the prosthesis. He will follow up with his primary care provider if any further adjustments need to be done or if he needs any further prescription for a new prosthesis. The patient and his wife understand and agree with this plan.
Patient presents to the office today with a complaint of an ill fitting the right leg prosthesis status post right below the knee amputation in 2007. he states that he has had no adjustments to his prosthesis since she was discharged from the hospital following his amputation in 2007. He has gained significant weight since that time and is having an area of redness on his stump that he and his wife are concerned about. He is here today for further evaluation.
PHYSICAL EXAMINATION:
Patient is alert and oriented x3. He is in no acute distress. Moderately obese. His right leg demonstrates a below the knee amputation with prosthesis currently fitted. Skin is intact.
ASSESSMENT:
Ill fitting prosthesis status post right below the knee amputation
PLAN:
Patient is advised that we do not deal with fitting of prostheses, and I have referred him to Evergreen prosthetics and orthotics. A prescription is sent to Evergreen for repair of the prosthesis. He will follow up with his primary care provider if any further adjustments need to be done or if he needs any further prescription for a new prosthesis. The patient and his wife understand and agree with this plan.
