CPC Chapter 19- Evaluation and Management Practical Flashcards
CASE 1
IDENTIFICATION: The patient is a 37-year-old Caucasian lady.
CHIEF COMPLAINT: The patient is here today for follow-up (Established patient & established problem.) of lower extremity swelling. (Chief complaint)
HISTORY OF PRESENT ILLNESS: A 37-year-old with a history of dyslipidemia and chronic pain. (Although dyslipidemia and chronic pain are listed as a history, there is no documentation to support the conditions were treated at this encounter or that they affected the management of the current conditions. These conditions are not coded and are not taken into consideration for the level of medical decision making.) The patient is here for follow-up of bilateral lower extremity swelling. The patient tells me that the swelling responded to hydrochlorothiazide.
EXAM: Very pleasant, no acute distress (NAD). VITALS: P: 67, R: 18, Temp 98.6, BP: 130/85.
DATA REVIEW: I did review her labs, (Labs were reviewed; however, the labs are credited at the time the labs were ordered. No credit given for MDM.) and echocardiogram. (An echocardiogram is reviewed. The echocardiogram is credited at the time it was ordered. No credit given for MDM.) The patient does have moderate pulmonary hypertension.
ASSESSMENT:
- Bilateral lower extremity swelling: Improved with diuretics; this may be secondary to problem #2.(The extremity swelling is possibly due to pulmonary hypertension, but not certain, so it is coded separately for the diagnosis. Acute illness with systemic symptoms.)
- Pulmonary hypertension: Etiology is not clear at this time, will do a workup and possible referral to a pulmonologist.
PLAN: I think we will need to evaluate the etiology of the pulmonary hypertension. The patient will be scheduled for a sleep study.(A sleep study is ordered.)
What are the CPT® and ICD-10-CM codes reported?
99213
M79.89, I27.20
CASE 2
The patient is a 32-year-old male here for the first time. (This is a new patient.)
Chief Complaint: Left knee area is bothersome,(Chief complaint.) painful moderate severity. The patient also notes swelling in the knee area, limited ambulation, and inability to perform physical activities such as sports or exercises. The patient first noticed symptoms approximately 4 months ago. Problem occurred spontaneously. Problem is sporadic. Patient has been prescribed hydrocodone and meloxicam. Patient has had temporary pain relief with the medications. The meloxicam has caused digestion problems, so patient has avoided using it.
Past Medical History: Patient denies any past medical problems.
Surgeries: Patient has undergone surgery on the appendix.
Hospitalizations: Patient denies any past hospitalizations that are noteworthy.
Medications: Hydrocodone
Allergies: Patient denies having allergies.
Family History: Mother: No serious medical problems; Father: No serious medical problems.
Social History: Patient is married. Occupation: Patient is a chef.
Review of Systems:
Constitutional: Denies fevers. Denies chills. Denies rapid weight loss.
Eyes: Denies vision problems.
Ears, Nose, Throat: Denies any infection. Denies loss of hearing. Denies ringing in the ears. Denies dizziness. Denies a sore throat. Denies sinus problems.
Cardiovascular: Denies chest pains. Denies an irregular heartbeat.
Respiratory: Denies wheezing. Denies coughing. Denies shortness of breath.
Gastrointestinal: Denies diarrhea. Denies constipation. Denies indigestion. Denies any blood in stool.
Genitourinary: Denies any urine retention problems. Denies frequent urination. Denies blood in the urine. Denies painful urination.
Integumentary: Denies any rashes. Denies having any insect bites.
Neurological: Denies numbness. Denies tremors. Denies loss of consciousness.
Hematologic/Lymphatic: Denies easy bruising. Denies blood clots.
Psychiatric: Denies depression. Denies sleep disorders. Denies loss of appetite.
Review of Previous Studies: Patient brings an MRI which is reviewed. (The provider reviews a prior MRI.) Large knee effusion. No lateral meniscal tear. No ACL/PCL tear. No collateral fracture. Medial meniscus tear with grade I signal.
Vitals: Height: 6’0”, Weight: 160
Physical Examination: Patient is alert, appropriate, and comfortable. Patient holds a normal gaze. Pupils are round and reactive. Gait is normal. Skin is intact. No rashes, abrasions, contusions, or lacerations. No venous stasis. No varicosities. Reflexes are normal patellar. No clonus.
Knee: Range of motion is approximately from 5 to 100 degrees. Pain with motion. No localized pain. Negative mechanical findings. There is an effusion.(Effusion is collection of fluid around the knee.) Patella is tracking well. No tenderness. Patient feels pain especially when taking stairs or squatting.(Pain is a symptom of the final diagnoses and is not reported separately.)
Hip: Exam is unremarkable. Normal range of motion, flexion approximately 105 degrees, extension approximately 10 degrees, abduction approximately 25 degrees, adduction approximately 30 degrees, internal rotation approximately 30 degrees, external rotation approximately 30 degrees.
Neck: Neck is supple. No JVD.
Impression:
- Infective synovitis of the left knee
- Contracture of the left knee
- Possible medial meniscal tear of right knee (This is an undiagnosed new problem. More testing is required to determine the extent of the injury.)
Assessment and Plan: A discussion is held with the patient regarding his condition and possible treatment options. Patient has GI upset.(GI update is taken into consideration when providing a plan, although there are no details provided to expand on that or to report it as an additional diagnosis.) Patient is recommended to take Motrin 400 two to three times a day (Over-the-counter (OTC) medication.), discussion is held regarding proper use and precautions. Patient is given a prescription for physical therapy.(Physical therapy ordered.) We will obtain an MRI (MRI ordered.) to rule out potential medial meniscus tear. Patient is instructed to follow up with PMD with labs.(No indication the labs were ordered or reviewed at this encounter.) Patient is referred to Dr. XYZ. Patient may need arthroscopy if patient does have medial meniscus tear and repeat effusion. (Plan for future encounters but not addressed during this encounter.)
What are the CPT® and ICD-10-CM codes reported?
99203
M65.162, M24.562
CASE 3
Susan is a 67 years-old female and she is referred by Dr. R with a suspicious neoplasm of her left arm.(Chief Complaint) She has had it for about a year, but it has grown a lot these last few months. (Related to surgery.) I had the privilege of taking a skin cancer off her forearm in the past. (Established patient.)
PAST MEDICAL HISTORY: Hypertension, arthritis.
ALLERGIES: None.
MEDICATIONS: Benicar and Vytorin.
SOCIAL HISTORY: Cigarettes: None.
PHYSICAL EXAMINATION: On examination, she has a raised lesion. It is a little bit reddish and is on her left proximal arm. It has a little bumpiness on its surface. (Related to surgery.)
MEDICAL DECISION MAKING: Suspicious neoplasm, left arm.
My guess is this is a wart, but it may be a keratoacanthoma (Possible diagnoses are not coded.) as Dr. R thinks it is. After obtaining consent, we infiltrated the area with 1cc of 1% lidocaine with epinephrine, performed a 3-mm punch biopsy of the lesion, and then I shaved the rest of the lesion off and closed the wound with 3-0 Prolene.(Punch biopsy and shaving of the lesion are performed.) We will see her back next week to go over the results.
What are the CPT® and ICD-10-CM codes reported?
11300
D49.2, Z85.828
CASE 4
AGE: 33-year-old – Established patient
VITAL SIGNS: TEMPERATURE: 98.9°F Tympanic, PULSE: 97 Right Radial, Regular, BP: 114/70 Right Arm Sitting, PULSE OXIMETRY: 98% , WEIGHT: 161 lbs.
CURRENT ALLERGY LIST: LORTAB
CURRENT MEDICATION LIST:
LUNESTA ORAL TABLET 3 MG, 1 Every Day At Bedtime, As Needed
PROZAC ORAL CAPSULE CONVENTIONAL 40 MG, 1 Every Day
LEVOTHYROXINE SODIUM ORAL TABLET 100 MCG, 1 Every Day for thyroid
MELOXICAM ORAL TABLET 15 MG, 1 Every Day for joint pain
IMITREX ORAL TABLET 100 MG, 1 tab po as directed , can repeat after 2 hours for migraines, max 2 per day
PHENERGAN 25 MG, 1 Every 4-6 Hours, As Needed for nausea
CHIEF COMPLAINT: Here for a comprehensive annual physical and pelvic examination. (Patient is seen for a routine Pap smear and comprehensive physical exam. This will be a preventive visit.)
HISTORY OF PRESENT ILLNESS: Pt here for routine pap and physical. Pt reports episode of syncope two weeks ago. Pt went to ER and had EKG, CXR and labs and says she was sent home and per her report everything was normal. She denies episodes since that time. She does occasionally have mild mid-epigastric discomfort but no breathing problems or light-headedness. Good compliance with her thyroid meds. (Discussion of meds for thyroid. This is not sufficient enough to bill a problem visit along with the preventive visit.)
PAST MEDICAL HISTORY: Depression.
FAMILY HISTORY: no cancer or heart disease, mother has hypertension.
SOCIAL HISTORY: TOBACCO USE: Currently smokes 1 1/2 PPD, has smoked for 15 to 20 years.
REVIEW OF SYSTEMS: Patient denies any symptoms in all systems except for HPI.
PHYSICAL EXAM: (Comprehensive physical exam.)
CONSTITUTIONAL: Well developed, well-nourished individual in no acute distress.
EYES: Conjunctivae appear normal. PERLA
ENMT: Tympanic membranes shiny without retraction. Canals unremarkable. No abnormality of sinuses or nasal airways. Normal oropharynx.
NECK: There are no enlarged lymph nodes in the neck, no enlargement, tenderness, or mass in the thyroid noted.
RESPIRATORY: Clear to auscultation and percussion. Normal respiratory effort. No fremitus. CARDIOVASCULAR: Regular rate and rhythm. Normal femoral pulses bilaterally without bruits. Normal pedal pulses bilaterally. No edema.
CHEST/BREAST: Breasts normal to inspection with no deformity, no breast tenderness or masses.(Breast exam.)
GI: Soft, non-tender, without masses, hernias or bruits. Bowel sounds are active in all 4 quadrants.
GU: EXTERNAL/VAGINAL: Normal in appearance with good hair distribution. No vulvar irritation or discharge. Normal clitoris and labia. Mucosa clear without lesions. Pelvic support normal.(Thin prep Pap smear collection.)
CERVIX: The cervix is clear, firm and closed. No visible lesions. No abnormal discharge. Specimens taken from the cervix for thin prep pap smear.
UTERUS: Uterus non-tender and of normal size, shape and consistency. Position and mobility are normal.(Pelvic exam.)
ADNEXA/PARAMETRIA: No masses or tenderness noted.
LYMPHATICS: No lymphadenopathy in the neck, axillae, or groin.
MUSCULOSKELETAL EXAM: Gait intact. No kyphosis, lordosis, or tenderness. Full range of motion. Normal rotation. No instability.
EXTREMITIES: BILATERAL LOWER: No misalignment or tenderness. Full range of motion. Normal stability, strength and tone.
SKIN: Warm, dry, no diaphoresis, no significant lesions, irritation, rashes or ulcers.
NEUROLOGIC: CNs II-XII grossly intact.
PSYCHIATRIC: Mood and affect appropriate.
LABS/RADIOLOGY/TESTS: The following labs/radiology/tests results were discussed with the patient: Alb, Bili, Ca, Cl, Cr, Glu, Alk Phos, K, Na, SGOT, BUN, Lipid profile, CBC, TSH, PAP smear.
ASSESSMENT/PLAN:
UNSPECIFIED ACQUIRED HYPOTHYROIDISM
What are the CPT® and ICD-10-CM codes reported?
99395
Z00.00, Z01.419, E03.9
CASE 5
NEW PATIENT OFFICE VISIT (This is a new patient.)
CHIEF COMPLAINT: Right lower quadrant abdominal pain.(Chief complaint.)
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old who presents with diffuse right lower abdominal pain.(Specificity of the location of the pain, which is required for the diagnosis.) The pain tends to be located near his right groin. He states that it has been present since the summer of 20XX. He was doing some significant activity at that time, including significant manual labor in his yard. It was at that time that he began to notice the symptoms. He continued to work in construction throughout the summer and fall. His symptoms continued through this time and only recently, as he has limited his activity, has the pain improved. He does not have any obstructive symptoms. He has not had previous inguinal hernia repair. He was seen by his primary care provider who thought he may have a spigelian type hernia and thus he has been sent to my clinic for evaluation of this problem.
PAST MEDICAL HISTORY: Low back pain, osteoarthritis, hypertension, and anxiety.
PAST SURGICAL HISTORY: Anal fistulotomy, appendectomy, patent foramen ovale closure, multiple arthroscopies, carpal tunnel release bilaterally, hand surgery for tendon releases, and bilateral cataract extraction.
ALLERGIES: He gets nausea and vomiting with narcotics, but otherwise has no true medication allergies.
CURRENT MEDICATIONS: Clonazepam, AndroGel, multivitamins.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is retired. He tries to exercise regularly. He does not smoke or drink.
REVIEW OF SYSTEMS: An 11-point review of systems was undertaken and, except for some mild upper respiratory tract infection type symptoms and some low back pain, was essentially negative.
PHYSICAL EXAMINATION: Vital Signs: Temperature is 96.4. Heart rate is 72. Blood pressure is 164/92. Respiratory rate is 15. Height is 5 feet 0 inches. Weight is 199 pounds. HEENT: The sclerae are anicteric and the oropharynx is clear. Neck: No jugular venous distension or lymphadenopathy. Chest: Clear to auscultation bilaterally. Cardiac: Regular rate without murmurs. Abdomen: Soft, nontender, and nondistended with no palpable intraabdominal abnormalities of note. Specifically, there are no palpable anterior abdominal wall fascial abnormalities of note. Back: No CVA tenderness and no spinal abnormalities. Groin: Both the right and left inguinal regions are intact with no evidence of hernia. There are no spermatic cord or testicular abnormalities. Extremities: No clubbing, cyanosis, or edema.
ASSESSMENT: Right groin pain, improving with limitation of activity.
PLAN: This patient most likely has one of two issues that are responsible for his symptoms.(Although the provider has two differential diagnoses, neither is at a high risk of morbidity.) One would be an occult hernia on the right side. This would present with pain without a palpable hernia on examination. This is where the posterior wall is disrupted and can lead to the same symptoms as an inguinal hernia, but without a palpable hernia. In this situation, patients typically do not get very much relief of their symptoms by decreasing their activity as one is continually utilizing the abdominal wall musculature and remain symptomatic from the hernia. Treatment would require laparoscopic surgery.(Possible surgical treatment option.) The other possible pathology would be an abdominal wall injury such as a muscle pull or strain. This typically would get better with rest and since the patient is stating that his symptoms have improved over the last month or so with decreasing his activity then I would expect that he would continue to improve with conservative management. The patient agrees with the plan of continued decreased activity for the next four to eight weeks.(Conservative treatment if rest is chosen.) He has not had any projects planned around his house and is not going to participate in construction at this time. He will get back to his normal activity in March. He will pay attention to his symptoms and if he does have recurrence of his symptoms with increasing physical activity, he will contact my office to arrange follow-up.
What are the CPT® and ICD-10-CM codes reported?
99203
R10.31
CASE 6
Hospital progress note
Subjective: Patient is without complaint. She states she feels much better. No vomiting or diarrhea. She did have bowel movement yesterday. No shortness of breath, no chest pain.
The patient and daughter were questioned again about her cardiac history. She denies any cardiac history. She has no orthopnea, no dyspnea on exertion, no angina in the past and she has never had any heart problems in the past.
Case discussed yesterday with Dr. Williams and I am waiting to find out on her surgery date.
Objective:
Vital Signs: Shows a T-max of 99.6, T-current 98, pulse 72, respirations 18. Blood pressure 154/65, 02 sat 96% on room air. Accu-checks, 113, 132, 96, 98.
General: No apparent distress, oriented x 3, pleasant Spanish-speaking female.
Head, Ears, Eyes, Nose, Throat: Normocephalic, atraumatic. Oropharynx pink and moist. Left eye has sclera erythema. Pupils equal, round, and reactive to light accommodation (PERRLA).
Laboratory Data: Shows C Diff-toxin negative. Sodium 129, potassium 3.4, chloride 96, CO2 27, glucose 72, BUN 12, creatinine 0.6. Urine culture positive for E. coli, sensitive to Levaquin.
Assessment:
- Cholelithiasis
- Cystitis
- Conjunctivitis
- Hyponatremia
- Hypokalemia
- Diabetes mellitus type 2
- Hypertension
If the patient is not to go to surgery today, will feed the patient and likely discharge her if she tolerates regular diet. Will add Norvasc 5 mg p.o. daily. Also pleural effusion, small. Will repeat a chest-x-ray PA and lateral this morning to evaluate that.
What are the CPT® and ICD-10-CM codes reported?
99232
K80.20, N30.90, H10.9, E87.1, E87.6, E11.9, I10
CASE 7
Discharge summary
Hospital course:
The patient was hospitalized two days ago with nausea and vomiting. She had an uneventful hospital course. She was diagnosed with cholelithiasis. General surgery was consulted. Dr. Williams thought this was perhaps causing her upper GI symptoms. She was scheduled for surgery on Monday. She was tolerating a regular diet. Her nausea and vomiting resolved and she desired to be dismissed home. She was found to have a bladder infection. She was started on Levaquin and she also had left eye conjunctivitis and she was given Clloxan eye ointment for that.
Discharge Diagnoses:
- Cholelithiasis
- Cystitis
- Conjunctivitis
- Hyponatremia
- Diabetes mellitus type 2
- Hypertension
Discharge Medications:
- Levaquin 500 mg p.o. daily x2 days
- Ciloxan ointment, apply b.i.d.to left eye x 4 days/
- Zofran 4 mg p.o. q. 4 hours p.r.n. nausea, vomiting #20
- Benadryl 25 mg p.o. daily p.r.n. rash
- Diovan 320 p.o. daily
- Calcium 600 mg p.o. daily
- Vitamin C 500 mg p.o. daily.
- Metformin 1000 mg p..o. daily
- Lipitor 20 mg p.o. at bedtime
- Coreg CR 20 mg p.o. daily.
Discharge Diet: Cardiac
Activities: ad lib
Discharge Instructions: Patient to be NPO after midnight Sunday.
Dismiss: Home
Condition: Good
Follow-up: Follow-up with me in 1 week. Follow-up on Monday morning for cholecystectomy. NPO after midnight on Sunday.
What are the CPT® and ICD-10-CM codes reported?
99238
K80.20, N30.90, H10.9, E87.1, E11.9, Z79.84, I10
CASE 8
XYZ Nursing Home
Subjective: The patient appears to be a little more altered than normal today. He is in some obvious discomfort. However, he is not able to communicate due to his mental status. Patient does appear fairly anxious.
Physical Exam: Glucoses have been within normal limits. Patient has had poor p.o. intake, however, over the last 2-3 days. Temperature is 97, pulse is 79, respirations 20, blood pressure 152/92, and oxygen saturation 97% on room air. Patient can be aroused. Extraocular movements are intact. Oral pharynx is clear. Lungs are clear to auscultation bilaterally. Heart has a regular rate and rhythm. Abdomen is nontender and nondistended. Patient is able to move all extremities. He does have some mild pain over the apex of his right shoulder and bruising over the anterior lateral rib cage on the right side over approximately T8 to T10. No crepitus is noted. Patient indicates he hurts everywhere.
Ancillary studies: A.M. labs – none new this morning. X-ray shows no evidence of fracture with definitive arthritis. Patient has chronic distention of bowels. This is always atypical exam. Telemetry shows no significant new arrhythmias.
Assessment & Plan:
- Patient is an 84-year-old Caucasian male who presented after a fall with rib contusion, right shoulder pain and uncontrolled pain since. He has been on Tramadol. However, I believe this is making him more altered. Thus, we will back off on medications and see if he comes back more to himself. We may try a different medication at a low dose later today if patient’s mental status improves significantly. We will have patient out of bed three times a day. Physical therapy is working with the patient for significant deconditioning.
- Patient with elevated blood pressures upon admission and still running a little bit high. Cardizem has been added to the medication regimen recently. We will follow this and see what it does for his blood pressure in the long run. He is in no immediate danger currently.
- Very advanced dementia, will follow, continue on home medications.
- Coronary artery disease and congestive heart failure. These appear stable at this time.
- History of atrial fibrillation, sounds to be in regular rhythm currently and appears to be doing well on telemetry monitor. Again, Cardizem has been added for better control and blood pressure control.
- Type 2 diabetes mellitus. Glycemic control has been good. However, patient has had poor p.o. intake over the last 2-3 days, which may be due to pain. Thus, we will hold glipizide for now to prevent hypoglycemia.
- We will follow the patient closely and adjust medications as necessary.
What are the CPT® and ICD-10-CM codes reported?
99309
S20.211A, M25.511, R03.0, F03.90, I25.10, I50.9, I48.91, E11.9, Z79.84
CASE 9
Hospital Admission
Chief complaint: Nausea and vomiting, weakness
HPI: The patient is a 78-year-old Hispanic female with a history of diabetes, hypertension, and osteoporosis who was just discharged after hospitalization for gastroenteritis three days ago. She went home and was feeling fine, was tolerating regular diet until yesterday when she vomited. She stated she feels nauseated now, feels like she needs to throw up but cannot vomit. Her last bowel movement was yesterday. She stated it was diarrhea and states she has extreme weakness. No melena or hematochezia. No shortness of breath, no chest pain.
Medical History: Diabetes mellitus type 2. Hypertension. Osteoporosis.
Surgical History: None
Medicines: Benadryl 25 mg daily, Diovan 320/25 one daily, calcium 600 daily, vitamin C 500 daily, multivitamin 1 tablet daily, Coreg CR 20 mg daily, Lipitor 20 mg at bedtime, metformin 1000 mg/day.
Allergies: MORPHINE
Social History: No tobacco, alcohol or drugs. She is a widow. She lives in Marta. She is retired.
Family History: Mother deceased after childbirth. Father deceased from asphyxia.
ROS: Negative for fever, weight gain, weight loss. Positive for fatigue and malaise.
Ears, Nose, Throat: Negative for rhinorrhea. Negative for congestion.
Eyes: Negative for vision changes.
Pulmonary: Negative for dyspnea.
Cardiovascular: Negative for angina.
Gastrointestinal: Positive for diarrhea, positive for constipation, intermittent changes between the two. Negative for melena or hematochezia.
Neurologic: Negative for headaches. Negative for seizures.
Psychiatric: Negative for anxiety. Negative for depression.
Integumentary: Positive for rash for which she takes Benadryl.
Genitourinary: Negative for dysfunctional bleeding. Negative for dysuria.
Objective:
Vital signs: Show a temperature max of 98.1, T-current 97.6, pulse 62, respirations 20, blood pressure 168/65. O2 sat 95% on room air. Accu-Chek, 135.
Generally: No apparent distress, alert and oriented x 3, pleasant Spanish speaking female.
Head, ears, eyes, nose, throat: Normocephalic, atraumatic. Oropharynx is pink and moist. No scleral icterus.
Neck: Supple, full range of motion.
Lungs: Clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm. No murmurs, gallops, rubs.
Abdomen: Soft, nontender, nondistended. Normal bowel sounds. No hepatosplenomegaly. Negative Murphy’s sign.
Back: Costovertebral angle tenderness
Extremeties: No clubbing, cyanosis or edema.
Laboratory Studies.
Shows a sodium 125, potassium 3.1, chloride 90, CO2 27, glucose 103, BUN 13, creatinine 0.7, white count 8.3, hemoglobin and hematocrit 12.6, 37.1, platelets 195, 000. Differential shows 76% neutrophils. Amylase 42, CK-MB 1.7, troponin 0.05, CPK 59. PTT 26.9. PT and INR 12.9 and 1.09. UA shows 500 leukocyte esterase, negative nitrite, 15 of ketones, 10 to 25 WBCs.
Gallbladder sonogram shows a 1.24 x 1 cm echogenic focus in the gallbladder, possibly representing gallbladder polyp or gallbladder mass. CT abdomen and pelvis shows cholelithiasis, small left pleural effusion, small indeterminate nodules both lung masses, no acute bowel abnormality and sclerotic appearance of right greater trochanter, no free air.
Assessment
- Nausea, vomiting, diarrhea, likely gastroenteritis
- Cystitis
- Hypokalemia
- Hyponatremia
- Cholelithiasis
- Diabetes mellitus type 2
- Hypertension
Plan: Will admit patient for IV hydration, add Levaquin 500 mg IV q 24 hours. Will add 20 mg KCl per L to IV fluid. Get a general surgery consult for cholelithiasis. Will check studies, fecal white blood cells, C. diff-toxin and fecal stool culture and sensitivity.
What are the CPT® and ICD-10-CM codes reported?
99222
R11.2, R19.7, N30.90, E87.6, E87.1, K80.20, E11.9, Z79.84, I10
CASE 10
Established patient
Chief complaint: thoracic spine pain
PROBLEM LIST:
- Rheumatoid arthritis, right and left hands.
- Compression fracture of the thoracic spine T11.
- Alcoholism.
- Depression/anxiety.
REVIEW OF SYSTEMS: His pain is significantly improved in his thoracic spine. He does have low back pain. He has a history of chronic low back pain. He is still wearing a thoracic support brace. He is going to follow up with Dr. X’s office in about six weeks or so. Since I have seen him last, he had a small flare of arthritis after his Humira injection. This resolved after 2-3 days. He had pain and stiffness in his hands. Currently he denies any pain and stiffness in his hands. He has one cystic mass on his left hand, second distal pad that is bothersome.
CURRENT MEDICATIONS: Vasotec 20mg a day, Folic Acid 1mg a day, Norvasc 5mg a day, Pravachol 40mg a day, Plaquenil 400mg a day, Humira 40mg every other week, Celexa 20mg a day, Klonopin .5mg as needed, aspirin 81mg a day, Ambien 10mg as needed, Hydrocodone as needed.
PHYSICAL EXAM: He is alert and oriented in no distress. Gait is unimpaired. He is wearing the thoracic brace. Spine ROM is not assessed. Lungs: Clear. Heart: Rate and rhythm are regular.
MUSCULOSKELETAL EXAM: There is generalized swelling of the finger joints without any significant synovitis or tenderness. There is a cystic mass on the pad of his second left finger, which is tender. Remaining joints are without tenderness or synovitis.
REVIEW OF DEXA(Dual Energy X-ray Absorptiometry) SCAN: (Performed in office today) There is low bone density with a total T-score of -1.1 of the lumbar spine. Compared to previous it was -0.8. There has been a reduction by 3.6%. T-score of the left femoral neck -1.1, Ward’s triangle -2.4, and total T-score is -0.8 compared to previous there has been a 7% reduction from last year.
ASSESSMENT:
- Seronegative rheumatoid arthritis in both hands. He is doing fairly well. He does have a cystic mass, which seems to be a synovial cyst of the left second digit. He was wondering if he could have this aspirated.
- Senile osteoporosis and continued care for compression pathologic fracture. He is being treated for osteoporosis because of this. He is tolerating Fosamax well. He is also using Miacalcin nasal spray temporarily to help and it has been effective.
PLAN:
- Continue current medications as listed above. Refills sent for Fosamax and Norvasc. Continue using thoracic brace.
- Aspirate the synovial cyst in the left second finger.
- Follow up in about 6-8 weeks.
- Repeat labs prior to visit.
Procedure Note: With sterile technique and Betadine prep, the radial side of the second finger is anesthetized with 1 cc 1% Lidocaine for a distal finger block. Then the synovial cyst is punctured and material was expressed under the skin. I injected it with 20 mg of Depo-Medrol. He will keep it clean and dry. If it has any signs or symptoms of infection, he will let me know.
What are the CPT® and ICD-10-CM codes reported?
99214-25, 20612-F1, 77080
J1020, M06.041, M06.042, M71.342, M80.08XD
