Expert educator Doris Branker CPC, CIRCC, CPMA, CPC-I, CANPC, CEMC will walk attendees through the 2021 update for office and outpatient E/M visits including the new definitions, descriptors and guidelines. Branker will also show attendees how to code this note. The webinar and has been approved for 1 AAPC CEU.
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Date: 12/20/2021
Chief complaints:
1. B/L hand pain
2. Upper back pain
3. Tailbone pain
History of Present Illness:
46 y/o F pt was referred by her internist for evaluation and management of mid-low back pain that radiates to BLE. Pt received trigger point injections to the L lower back on 10/24/2020 with 50% relief until she was doing laundry. Pt then had 10 days of buttock/hip pain. Pt reports that pain meds and muscle relaxers did not help and caused her to lose her appetite. Pt rides an exercise bike when she is feeling well, 5 times a week for 5-20 minute sessions. Today, pt reports a pain level of 7/10 in her B/L hands, upper back, and tailbone area. TENS does not help the pain. She is requesting a neck/upper back injection today. Gabapentin has not helped for her hand pain. She does not have numbness or tingling. She reports that gripping a pot is painful.
Past Medical History:
- Arthritis
- Anemia, unspecified.
- Herniated nucleus pulposus, L5-S1.
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- R MCP osteoarthritis.
- De Quervain's tenosynovitis, left.
Allergies: None
Current Medications:
- Taking Cyclobenzaprine HCl 5 MG Tablet 1 tablet as needed Orally Two times a day
- Taking Gabapentin 600 MG Tablet 1 capsule Orally Three times a day
- Taking Tramadol HCl
- Taking Eliquis
- Taking Iron (Ferrous Sulfate)
- Taking Duloxetine HCl 30 MG Capsule Delayed Release Particles 1 capsule Orally Twice a day
Gabapentin: Lack of Therapeutic Effect
Surgical History:
- DVT surgery 11/22/2018
- Uterine fibroid surgery 11/23/2018
- Hospitalization/Major Diagnostic Procedures:
- No Hospitalization History.
Family History:
- No Family History documented.
Social History:
- Tobacco Use/Smoking: Are you a nonsmoker. Yes
Review of systems:
- Numbness/Tingling No
- Shortness of breath No
- Chest Pains No
- Double Vision No
- Constipation No
- Diarrhea No
- Skin Rashes No
- Easily Sweats No
- Depressed Moods No
- Bruised Easily No
- Fever No
- Chills No
- B/L hand pain. upper back pain. tailbone pain.
Vitals:
HR 84 /min, BP 110/74 mm Hg, Wt 196 lbs, Pain scale 7 1-10, Wt-kg 88.9 kg.
Examination:
GENERAL APPEARANCE: in no acute distress, well developed, well nourished. HEAD: normocephalic, atraumatic. EYES: pupils equal, round, reactive to light. NECK/THYROID: tenderness and trigger points in left neck, pain in left lower border of scapula, scapula movements do not elicit pain, neck flexion/left rotation/left lateral flexion elicit scapular pain, restricted ROM equal B/L rotation, restricted left lateral flexion, less restricted right lateral flexion, FROM flexion/extension. SKIN: no observable rash, warm and dry. CHEST: normal respirations at rest. BACK: pain in left lower border of scapula, scapula movements do not elicit pain, neck flexion/left rotation/left lateral flexion elicit scapular pain. EXTREMITIES: Left wrist positive de quervaine, R wrist with MCP osteoarthritis, negative Tinel B/L, positive Finklestein on the left, painful ROM of R MCP. NEUROLOGIC: nonfocal, motor strength normal upper and lower extremities, sensory exam intact. PSYCH: alert, oriented, cooperative with exam, good eye contact, speech clear.
10-panel POC urine toxicology done in office today positive for TCA and cocaine. Confirmatory testing will be ordered
Assessment:
Low back pain – M54.5 (Primary)
De Quervain's tenosynovitis, left – M65.4
Cervical disc displacement – M50.20
- Cervical disc displacement
- Refill Gabapentin Capsule, 400 MG, 1 capsule, Orally, Three times a day, 30 day(s), 90, Refills
- Start Lidocaine Lotion, 4 %, 1 application to affected area as needed, Externally, Three times a day, 30 days, 120
- Notes: Consider cervical MRI. Referred pain to left scapular area. Cervical ESI for pain control
Metacarpophalangeal joint pain of right hand – M79.641
- Metacarpophalangeal joint pain of right hand
- Start Diclofenac Sodium Gel, 1 %, 1g application to affected area, Transdermal, Four times a day, 30 day(s),300 Gram
- Notes: History of trauma – likely OA. Possible underlying tendinosis across joint.
Other long term (current) drug therapy – Z79.899
Cervicalgia – M54.2
- The patient has cervical spinal and disc pathology necessitating treatment and support. A cervical collar, L0180 is recommended for postural support, pain relief, and posterior column offloading. Patient was prescribed, dispensed, fitted, and trialed with the orthotic. Ability to doff and don the orthosis was demonstrated. This may be used as needed. The patient may call if there are questions or concerns. This durable medical device is medically necessary and appropriate and authorization is requested. Dispensed today.
- Pt scheduled for a OR cervical injection. Authorization is requested.
Left wrist pain – M25.532
- Notes:
- A left wrist-hand-finger, L3809, brace was prescribed, dispensed, fitted and trialed. The patient demonstrated understanding in its use, and an ability to doff and don the orthoses. These may be used as needed. The patient is to call if there are questions. These devices are medically necessary and appropriate for this condition. Authorization is requested for purchase. Dispensed today.