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AAPC Chapter 19 A & B Questions & Answers

Terms in this set (73)

Case 1: Established Patient Office Visit

Chief Complaint: Right shoulder pain |1|

This is a 47-year-old, otherwise healthy, right-hand-dominant male toolmaker with a 6-8 week history of gradual insidious onset of right shoulder pain. He has noted popping along the medial aspect of the scapula but this is not particularly associated with the pain. The pain seems to be localized more laterally. He has been taking Naprosyn® for some low back discomfort, which also helps his shoulder.

ROS: No HEENT, respiratory, cardiovascular, gastrointestinal, genitourinary, or nerve complaints. MS is positive for joint pain, muscle tenderness, and weakness.

Past History: Medications:
Naprosyn®, Allergic to Penicillin. Prior surgery on lower back (1994).

Family History: None

Social History:
Positive for tobacco and alcohol use.

Physical Examination:
Right shoulder is non-swollen. No deformity. No muscular atrophy. He does have crepitus that localizes to his scapulothoracic articulation medially and posteriorly, but there is no tenderness or apparent pain. He has full active range of motion. No instability. Negative impingement. He does have some pain primarily with resisted supraspinatus function, but no distinct weakness.

X-ray:
X-rays, three views of the right shoulder viewed in office, |3| show normal anatomic relationships. No soft tissue calcifications. Acromial humeral interval maintained. The X-ray will be officially read by the radiologist.

Assessment and Plan:
Right rotator cuff tendonitis. |2| After discussion of treatment options, he wished to proceed with shoulder injection done with 2 cc of Xylocaine® under a sterile technique from a posterior approach. |4| He is started on a rotator cuff exercise program. Return in 3-4 weeks for follow up.

|1| Chief complaint
|2| Number and Complexity of Problems: Acute uncomplicated injury/illness
|3| Amount and Complexity of Data: X-rays independently reviewed by physician. Will be reported by the radiologist.
4| Risk of Complications: Joint injection; shoulder



What are the CPT® and ICD-10-CM codes reported?
NEW PATIENT OFFICE VISIT
CHIEF COMPLAINT: Low back pain with radiating pain into the legs.
HISTORY OF PRESENT ILLNESS: A 78-year-old female with long-standing back pain. She is noted to have undergone previous epidurals. She has been diagnosed with spinal stenosis for approximately 10 years. She denies bowel or bladder dysfunction or saddle anesthesia. She offers a weakness of the extremity and numbness. She offers no unexpected weight loss, no recent trauma. She denies previous back surgery. She is a new patient to our office.
CURRENT MEDICATIONS: Lisinopril, Lovastatin, glipizide, Arimidex, Naproxen, Neurontin, Xalatan, multivitamin.
ALLERGIES: Codeine.
PAST MEDICAL HISTORY: Breast cancer, hypertension, diabetes, prior history of spinal stenosis.
REVIEW OF SYSTEMS: Denies any cardiac arrhythmia or unstable angina. No pulmonary disorders. Denies thyroid disease. No renal dysfunction. No history of stroke or seizure. She is without any unexpected weight loss or constitutional signs of infection.
SOCIAL HISTORY: She is ambulatory without assist device. Denies tobacco and alcohol use.
FAMILY HISTORY: Diabetes and cancer.
PHYSICAL EXAMINATION: Side-to-side comparison shows no asymmetry, no pronounced atrophy. She has a pronounced straight leg raise on the right and also a contralateral straight leg raise on the left, but her discomfort is to a lesser degree.
Reflexes are symmetric. Motor strength is noted to be 5/5 with ankle dorsi and plantar flexion, great toe extension, knee flexion/extension, hip abduction. She has 4/5 motor strength with hip flexion. Her hips are supple on examination. She has decreased sensation to L4-L5 level.
ANCILLARY STUDIES: Independent interpretation of previous MRI from November 20XX shows evidence of spinal stenosis at L3-4, L4-5, and 5-S1. There is neural foramenal narrowing at these levels. Findings are most noted at L4-5. In addition, there is facet hypertrophy and ligamentous thickening. Cord maintained a normal signal.
IMPRESSION: Spinal stenosis with radicular leg pain.
PLAN: A repeat of the MRI will be obtained. She will return for reassessment following this study. Likely begin another course of epidural steroids. I have also recommended physical therapy. Further recommendations are pending her MRI.

What E/M code is reported?
NEW PATIENT OFFICE VISIT
CHIEF COMPLAINT: Right inguinal hernia.
HISTORY OF PRESENT ILLNESS: This 44-year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago in the shower he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal physician, Dr. X, told him that it would be dangerous to have this become incarcerated in the back country.
PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None.
REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69.
GENERAL APPEARANCE: He is a very muscular well-built man in no distress.
SKIN: Normal.
HEAD AND NECK: Sclerae are clear. External ocular eye movements are full. Trachea is midline. Thyroid is not felt.
CHEST: Clear.
HEART: Regular.
ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure by history and by physical examination that he has a rather small indirect inguinal hernia. His cord and testicles are normal.
NEURO: Grossly intact to motor and sensory examination.
IMPRESSION: Right indirect inguinal hernia.
PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. I gave him the scheduling number and he will call and arrange the operation.

What E/M code is reported?
Case 2
The patient is a 32-year-old male here for the first time.
Chief Complaint: Left knee area is bothersome, 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. 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. Patella is tracking well. No tenderness. Patient feels pain especially when taking stairs or squatting.
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:
1.Infective synovitis of the left knee
2.Contracture of the left knee
3.Possible medial meniscal tear of right knee
Assessment and Plan: A discussion is held with the patient regarding his condition and possible treatment options. Patient has GI upset. Patient is recommended to take Motrin 400 two to three times a day, discussion is held regarding proper use and precautions. Patient is given a prescription for physical therapy. We will obtain an MRI to rule out potential medial meniscus tear. Patient is instructed to follow up with PMD with labs. Patient is referred to Dr. XYZ. Patient may need arthroscopy if patient does have medial meniscus tear and repeat effusion.

What are the CPT® and ICD-10-CM code(s) reported?
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 examinations.
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.
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:
Constitutional: Well developed, well-nourished individual in no acute distress.
Eyes: Conjunctivae appear normal. PERRLA
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.
GI: Soft, non-tender, without masses, hernias or bruits. Bowel sounds are active in all four 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. 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.
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 code(s) reported?
Case 5
NEW PATIENT OFFICE VISIT
CHIEF COMPLAINT: Right lower quadrant abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old who presents with diffuse right lower abdominal pain. 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. 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. 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. 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 code(s) reported?
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:
1.Cholelithiasis
2.Cystitis
3.Conjunctivitis
4.Hyponatremia
5.Hypokalemia
6.Diabetes mellitus type 2
7.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 code(s) reported?
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:
1.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.
2.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.
3.Very advanced dementia, will follow, continue on home medications.
4.Coronary artery disease and congestive heart failure. These appear stable at this time.
5.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.
6.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.
7.We will follow the patient closely and adjust medications as necessary.

What are the CPT® and ICD-10-CM code(s) reported?
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.
Extremities: 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
1.Nausea, vomiting, diarrhea, likely gastroenteritis
2.Cystitis
3.Hypokalemia
4.Hyponatremia
5.Cholelithiasis
6.Diabetes mellitus type 2
7.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 code(s) reported?
Case 10
Established Patient
Chief Complaint: Thoracic spine pain
Problem List:
1.Rheumatoid arthritis, right and left hands.
2.Compression fracture of the thoracic spine T11.
3.Alcoholism.
4.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 20 mg a day, Folic Acid 1mg a day, Norvasc 5 mg a day, Pravachol 40 mg a day, Plaquenil 400 mg a day, Humira 40 mg every other week, Celexa 20 mg, a day, Klonopin .5 mg as needed, aspirin 81 mg a day, Ambien 10 mg 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:
1.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.
2.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:
1.Continue current therapy.
2.Aspirate the synovial cyst in the left second finger.
3.Follow up in about 6-8 weeks.
4.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 code(s) reported?
NEW PATIENT OFFICE VISIT

CHIEF COMPLAINT: Low back pain with radiating pain into the legs.

HISTORY OF PRESENT ILLNESS: A 78-year-old female with long-standing back pain. She is noted to have undergone previous epidurals. She has been diagnosed with spinal stenosis for approximately 10 years. She denies bowel or bladder dysfunction or saddle anesthesia. She offers a weakness of the extremity and numbness. She offers no unexpected weight loss, no recent trauma. She denies previous back surgery. She is a new patient to our office.

CURRENT MEDICATIONS: Lisinopril, Lovastatin, glipizide, Arimidex, Naproxen, Neurontin, Xalatan, multivitamin.

ALLERGIES: Codeine.

PAST MEDICAL HISTORY: Breast cancer, hypertension, diabetes, prior history of spinal stenosis.

REVIEW OF SYSTEMS: Denies any cardiac arrhythmia or unstable angina. No pulmonary disorders. Denies thyroid disease. No renal dysfunction. No history of stroke or seizure. She is without any unexpected weight loss or constitutional signs of infection.

SOCIAL HISTORY: She is ambulatory without assist device. Denies tobacco and alcohol use.

FAMILY HISTORY: Diabetes and cancer.

PHYSICAL EXAMINATION: Side-to-side comparison shows no asymmetry, no pronounced atrophy. She has a pronounced straight leg raise on the right and also a contralateral straight leg raise on the left, but her discomfort is to a lesser degree.
Reflexes are symmetric. Motor strength is noted to be 5/5 with ankle dorsi and plantar flexion, great toe extension, knee flexion/extension, hip abduction. She has 4/5 motor strength with hip flexion. Her hips are supple on examination. She has decreased sensation to L4-L5 level.

ANCILLARY STUDIES: Independent interpretation of previous MRI from November 20XX shows evidence of spinal stenosis at L3-4, L4-5, and 5-S1. There is neural foramenal narrowing at these levels. Findings are most noted at L4-5. In addition, there is facet hypertrophy and ligamentous thickening. Cord maintained a normal signal.

IMPRESSION: Spinal stenosis with radicular leg pain.

PLAN: A repeat of the MRI will be obtained. She will return for reassessment following this study. Likely begin another course of epidural steroids. I have also recommended physical therapy. Further recommendations are pending her MRI.

What E/M code is reported?
NEW PATIENT OFFICE VISIT

CHIEF COMPLAINT: Right inguinal hernia.

HISTORY OF PRESENT ILLNESS: This 44-year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago in the shower he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal physician, Dr. X, told him that it would be dangerous to have this become incarcerated in the back country.

PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None.

REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation.

PHYSICAL EXAMINATION:

VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69.

GENERAL APPEARANCE: He is a very muscular well-built man in no distress.

SKIN: Normal.

HEAD AND NECK: Sclerae are clear. External ocular eye movements are full. Trachea is midline. Thyroid is not felt.

CHEST: Clear.

HEART: Regular.

ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure by history and by physical examination that he has a rather small indirect inguinal hernia. His cord and testicles are normal.

NEURO: Grossly intact to motor and sensory examination.

IMPRESSION: Right indirect inguinal hernia.

PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. I gave him the scheduling number and he will call and arrange the operation.

What E/M code is reported?
Case 1: Established Patient Office Visit

Chief Complaint: Right shoulder pain |1|
This is a 47-year-old, otherwise healthy, right-hand-dominant male toolmaker with a 6-8 week history of gradual insidious onset of right shoulder pain. He has noted popping along the medial aspect of the scapula but this is not particularly associated with the pain. The pain seems to be localized more laterally. He has been taking Naprosyn® for some low back discomfort, which also helps his shoulder.

ROS: No HEENT, respiratory, cardiovascular, gastrointestinal, genitourinary, or nerve complaints. MS is positive for joint pain, muscle tenderness, and weakness.

Past History: Medications: Naprosyn®, Allergic to Penicillin. Prior surgery on lower back (1994).

Family History: None

Social History: Positive for tobacco and alcohol use.

Physical Examination:
Right shoulder is non-swollen. No deformity. No muscular atrophy. He does have crepitus that localizes to his scapulothoracic articulation medially and posteriorly, but there is no tenderness or apparent pain. He has full active range of motion. No instability. Negative impingement. He does have some pain primarily with resisted supraspinatus function, but no distinct weakness.

X-ray: X-rays, three views of the right shoulder viewed in office, |3| show normal anatomic relationships. No soft tissue calcifications. Acromial humeral interval maintained. The X-ray will be officially read by the radiologist.

Assessment and Plan:
Right rotator cuff tendonitis. |2| After discussion of treatment options, he wished to proceed with shoulder injection done with 2 cc of Xylocaine® under a sterile technique from a posterior approach. |4| He is started on a rotator cuff exercise program. Return in 3-4 weeks for follow up.

|1| Chief complaint
|2| Number and Complexity of Problems: Acute uncomplicated injury/illness
|3|Amount and Complexity of Data: X-rays independently reviewed by physician. Will be reported by the radiologist.
4| Risk of Complications: Joint injection; shoulder

Wat are the CPT® and ICD-10-CM codes reported?
Case 1: Emergency Department Visit

Chief complaint: Dizziness, nausea, vomiting.

History of Present Illness
A 43-year-old very pleasant gentleman with history of hypertension who presents to the emergency department with chief complaint of abrupt onset |1| of nausea, vomiting, and dizziness. |2| The patient said that while he was sitting, |3| he felt like the room was spinning and felt very unstable, |4| and had severe nausea. Denies any abdominal pain, |5| fever, chills, |6| headache, |7| or shortness of breath. |8| Symptoms are exacerbated by certain movements. |9| Denies any sick contacts. This is the first time this has ever happened. The patient arrived via EMS. After receiving 12.5 mg of Phenergan® |10| intravenously, he feels better at this time.
The patient said that he has some mild nausea. |11| He has had one episode of nonbloody, nonbilious emesis in the emergency room.

Past Medical History: Hypertension. |12|

Past Surgical History: Negative. |12|

Social History: Occasional alcohol use, nonsmoker, no drug use. |13|

Family History: Negative for hypertension |14|

Review of Systems
All pertinent positives and negatives as above, all 10 systems |15| reviewed and the remaining are negative.

Physical Examination
Temperature 97, heart rate 66, blood pressure 169/92, respiratory rate 20, O2 sat 97% on room air. General examination: The patient in no acute distress. |16| HEENT: Normocephalic, atraumatic. |17| Pupils are 4 and reactive. |18| There is a slight horizontal nystagmus with left lateral gaze. |19| Mucous membranes are moist. |20| Neck is supple. There is no Kernig's, no Brudzinskj's. Hallpike maneuver was negative. The patient was symptomatic with both directions. |21| Lungs are clear auscultation bilaterally. Chest symmetric. |22| Cardiovascular: S1, S2, regular rate and rhythm. |23| Abdomen is soft, nontender, |24| no CVA tenderness. |25| Neurologically, the patient is alert and oriented x3. Cranial nerves II-XII are grossly intact. Strength is 5/5. Reflexes are symmetric. Cerebellum is intact with good finger-to-nose. Sensation is grossly intact. |26| Lymph: No appreciable cervical, axilla, inguinal lymphadenopathy. |27|

Diagnostics

CBC: White blood cell count of 14, hemoglobin 15, hematocrit 45, platelets are 179.Chem-7 identifies glucose of 202, BUN of 13, creatinine 0.8. |28|

ED Course
The patient underwent an MRI of the brain, |29| which was interpreted as negative per the attending radiologist. He was treated with intravenous Zofran® |30| and oral Antivert®, |31| feels better at this time.

Plan: The patient will be discharged at this time. Advised to follow up with his primary care physician. Return if increased symptoms.

Diagnosis: Vertigo. |32|

Disposition: Discharged stable condition.

|1| HPI: Timing
|2| HPI: Associated signs and symptoms
|3| HPI: Context
|4| HPI: Quality
|5| ROS: Gastrointestinal
|6| ROS: Constitutional
|7| ROS: Neurological
|8| ROS: Respiratory
|9| HPI: Modifying factors
|10| HPI: Modifying factors
|11| HPI: Severity
|12| PFSH: Past Medical History
|13| PFSH: Social History
|14| PFSH: Family History
|15| ROS: Complete
|16| Organ System: Constitutional
|17| Body Area: Head
|18| Organ System: Eyes
|19| Organ System: Neurologic
|20| Organ System: Mouth
|21| Organ System: Neurologic
|22| Organ System: Respiratory
|23| Organ System: Cardiovascular
|24| Body Area: Abdomen
|25| Organ System: Genitourinary
|26| Organ System: Neurologic
|27| Organ System: Lymphatic
|28| Labs reviewed
|29| MRI ordered
|30| IV Zofran
|31| Oral meds
|32| Definitive diagnosis

What are the CPT® and ICD-10-CM codes reported?
New Patient History & PhysicalCHIEF COMPLAINT: Right chronic inguinal hernia.HISTORY OF PRESENT ILLNESS: This 44-year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago in the shower he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal provider, Dr. X told him it would be dangerous to have this become incarcerated in the back country.PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None.MEDICATIONS: Advair.ALLERGIES: None.REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation.PHYSICAL EXAMINATION:VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69.GENERAL APPEARANCE: He is a very muscular well-built man in no distress.SKIN: Normal.LYMPH NODES: None.HEAD AND NECK: Sclerae are clear. External ocular eye movements are full. Trachea is midline. Thyroid is not felt.CHEST: Clear to auscultation.HEART: Regular rhythm with no murmur.ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure he has by history and by physical examination a rather small indirect inguinal hernia. His cord and testicles are normal.IMPRESSION: Right chronic indirect inguinal hernia.PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. He was cautioned on the fact this could become an emergent situation if this becomes incarcerated. I gave him the scheduling number, and he will call and arrange the operation.What CPT® and ICD-10-CM codes are reported?