dgerry
Networker
Here is the documentation:
Chief Complaint
Right knee pain.
S: 14-year-old female dancer described her patella dislocating two weeks ago. She was able to reduce it herself. Has noted some pain over the medial knee. Has not had any previous eval and denies previous occurrence.
O: Past medical history and patient intake form reviewed and signed. Healthy female in no obvious discomfort. Knee is without swelling, ecchymosis, or effusion. Mild tenderness over the medial retinaculum. No swelling or defect. Negative Lachman. Collateral ligament stable. Gentle ROM supple without obvious subluxation.
R: X-ray of the knee reveals no fracture, no subluxation.
Miracle Knee Brace applied.
A: Status post patellar dislocation now reduced.
P: PT for quad strengthening.
What level new patient would this be coded as? Thanks!
Chief Complaint
Right knee pain.
S: 14-year-old female dancer described her patella dislocating two weeks ago. She was able to reduce it herself. Has noted some pain over the medial knee. Has not had any previous eval and denies previous occurrence.
O: Past medical history and patient intake form reviewed and signed. Healthy female in no obvious discomfort. Knee is without swelling, ecchymosis, or effusion. Mild tenderness over the medial retinaculum. No swelling or defect. Negative Lachman. Collateral ligament stable. Gentle ROM supple without obvious subluxation.
R: X-ray of the knee reveals no fracture, no subluxation.
Miracle Knee Brace applied.
A: Status post patellar dislocation now reduced.
P: PT for quad strengthening.
What level new patient would this be coded as? Thanks!
