graceroni13
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Received a denial saying that the level of the visit was not supported nor was the injection into the biceps tendon. Can somebody please look over this and tell me what codes they would use? I'm writing an appeal and would like for someone to give me their thoughts on this, thank you 
ACTIVE PROBLEMS
• Arthralgia - Knee / Patella / Tibia / Fibula
• Arthralgia - Shoulder Region
• Arthralgia - Ulna / Radius / Wrist
• Intermittent Hydroarthrosis Knee
• Knee Sprain Cruciate Ligament Anterior
• Malunion of Fracture Carpal Bones Scaphoid
• Tendonitis Bicipital
CHIEF COMPLAINT
The Chief Complaint is: Right wrist and shoulder pain.
HISTORY OF PRESENT ILLNESS
36 year old male.
He reported: Medication list reviewed.
36-year-old well known male patient of this office presents today for an evaluation regarding his right shoulder and right wrist.he reports pain in these areas for the previous 10+ years. He does not recall any injury precipitating his symptoms. Symptoms are generally mild in nature but they have been present for a long time and wishes to have an evaluation. Pain about the shoulder is primarily over the anterior aspect and feels deep and muscular. Pain about the wrist is present primarily near the base of the thumb/wrist area and is described as an achiness. He does recall breaking the first metacarpal of his right hand but denies any history of wrist fracture. Pain is worse with activity and improved with rest. Pain about the shoulder is rated at worst 6/10 where pain at the wrist is rated at worst 4/10. At rest patient has no pain at all in either area. He has not attempted any treatments for either area.
CURRENT MEDICATION
• Percocet 5-325 MG Tablet Take 1-2 po every 6 hours as needed for pain, 7 days, 0 refills
PAST MEDICAL/SURGICAL HISTORY
Arthroscopy Knee - Left.
SOCIAL HISTORY
Behavioral: No tobacco use, not a current smoker, and smoking status: Never smoker.
Alcohol: Alcohol use.
Drug Use: Not using drugs.
Marital: Currently married.
ALLERGIES
• No Known Allergies
FAMILY HISTORY
Family medical history non-contributory
REVIEW OF SYSTEMS
Systemic: No fever, no chills, no recent weight loss, and no recent weight gain.
Head: No headache.
Otolaryngeal: No epistaxis.
Cardiovascular: No chest pain or discomfort, no palpitations, and the heart rate was not fast.
Pulmonary: No dyspnea, no cough, and no wheezing.
Gastrointestinal: No dysphagia and no heartburn. No nausea, no vomiting, and no hematochezia.
Genitourinary: No hematuria and no increase in urinary frequency. No dysuria.
Endocrine: No polydipsia and no excessive sweating.
Hematologic: No easy bleeding and no tendency for easy bruising.
Neurological: No vertigo and no convulsions.
Psychological: No anxiety and no depression.
Skin: No rash and no sore:
PHYSICAL FINDINGS
• Vitals taken 12/04/2015 09:31 am
Height 72 in 65 - 75
Weight 180 lbs 125 - 225
Body Mass Index 24.4 kg/m2
Body Surface Area 2.04 m2
Cervical spine:
-Skin has no obvious lesions to inspection. No pain to palpation.
-ROM intact to flexion, extension, lateral flexion and rotation to the left and right.
-No instability appreciated.
-Strength 5/5. Sensation intact to light touch. No lymphadenopathy or swelling appreciated.
Left Shoulder:
Normal gross appearance without masses. Range of motion full without pain at the extremes of flexion, abduction and internal rotation. Strength 5/5 to resisted external rotation and abduction. Strength 5/5 to internal rotation, forward flexion and extension. No point tenderness to palpation over A.C. joint. No point tenderness over the proximal biceps tendon. Shoulder apprehension negative for instability anteriorly and posteriorly. Distal neuro vascular exam reveals 2+ pulses and intact sensation. No lymph edema appreciated. Deep tendon reflexes 2+.
Right Shoulder:
Normal gross appearance without masses. Range of motion full with mild pain at the extremes of flexion, abduction and internal rotation. Strength 5/5 to resisted external rotation and abduction. Strength 5/5 to internal rotation, forward flexion and extension. Mild tenderness to palpation over A.C. joint. Tenderness to palpation about the proximal biceps tendon. Pain with 90:90 testing. Shoulder apprehension negative. Distal neuro vascular exam intact.
Left wrist:
Full flexion and extension of the wrist. Full radial and ulnar deviation. Full pronation and supination of the forearm. 5 over 5 strength. Negative Tinel's signed. Negative Phalen's test. Full flexion and extension of the fingers and thumb. 5 over 5 strength. Intact sensation to light touch in the median and ulnar nerve distribution. Capillary refill intact.
Right wrist:
Full flexion and extension of the wrist. Full radial and ulnar deviation. Full pronation and supination of the forearm. 5 over 5 strength. Tenderness to palpation over the lateral aspect of the scaphoid. Palpable spur noted. Negative Tinel's signed. Negative Phalen's test. Full flexion and extension of the fingers and thumb. 5 over 5 strength. Intact sensation to light touch in the median and ulnar nerve distribution. Capillary refill intact.
TESTS
X-RAY - 3-view R SHOULDER:
- Bone structures are well mineralize
- No fractures, dislocations, or bone lesions are identified
- Moderate acromioclavicular arthrosis
X-RAY - AP ,Lat , and scaphoid view R wrist
- Bone structures are well mineralized
- No fractures, dislocations, or bone lesions are identified
- Spur off the distal/lateral aspect of the scaphoid. Mild to moderate arthrosis of the radioscaphoid joint
ASSESSMENT
Right shoulder pain
Right proximal biceps tendinitis
Right acromioclavicular arthrosis, primary
Right wrist pain
Right radiocarpal arthrosis, secondary to posttraumatic
Right scaphoid malunion to previously unknown fracture
PLAN
I discussed my findings with the patient. He was educated on his conditions and advised of the treatment options. He was given the opportunity to ask questions and all questions were answered to his satisfaction. In regards to the shoulder I would recommend a cortisone injection over the proximal biceps tendon. As for the wrist I would like him to be seen by our upper extremity specialist. After discussion of potential risks and complications including but not limited to, infection, neural-vascular damage, depigmentation of the skin, rupture of underlying tendons, failure to improve condition and possible worsening of condition, a verbal consent to proceed was obtained.
PROCEDURE:
The skin was prepped with betadine. Ethyl Chloride was topically applied for anesthesia. A 5cc cortisone injection containing equal amounts, 1% Lidocaine, 0.25% Marcaine, and 80 mg Depomedrol was given taking care to avoid inter-tendonous injection. The patient tolerated the procedure well. A bandaid was then applied to the puncture wound.
Ice to involved area
NSAIDs
Follow-up on an as-needed basis for this. He is scheduled for an ACL reconstruction on 12/9/15. The patient's hinged knee brace which she has been wearing since his initial patellar tendon repair on 9/3/15 is quite dirty and odiferous. We will present him with a new brace at this time.
The patient was prescribed a prefabricated brace for the above diagnosis. This was fitted to the patient with manual adjustments including bending, molding, shaping, trimming of straps, hinge adjustments for proper ROM as necessary for the best fit to the patient for comfort and effectiveness. The brace is provided due to weakness and or instability requiring stabilization by semi-rigid or rigid orthosis per the above stated diagnosis.
ACTIVE PROBLEMS
• Arthralgia - Knee / Patella / Tibia / Fibula
• Arthralgia - Shoulder Region
• Arthralgia - Ulna / Radius / Wrist
• Intermittent Hydroarthrosis Knee
• Knee Sprain Cruciate Ligament Anterior
• Malunion of Fracture Carpal Bones Scaphoid
• Tendonitis Bicipital
CHIEF COMPLAINT
The Chief Complaint is: Right wrist and shoulder pain.
HISTORY OF PRESENT ILLNESS
36 year old male.
He reported: Medication list reviewed.
36-year-old well known male patient of this office presents today for an evaluation regarding his right shoulder and right wrist.he reports pain in these areas for the previous 10+ years. He does not recall any injury precipitating his symptoms. Symptoms are generally mild in nature but they have been present for a long time and wishes to have an evaluation. Pain about the shoulder is primarily over the anterior aspect and feels deep and muscular. Pain about the wrist is present primarily near the base of the thumb/wrist area and is described as an achiness. He does recall breaking the first metacarpal of his right hand but denies any history of wrist fracture. Pain is worse with activity and improved with rest. Pain about the shoulder is rated at worst 6/10 where pain at the wrist is rated at worst 4/10. At rest patient has no pain at all in either area. He has not attempted any treatments for either area.
CURRENT MEDICATION
• Percocet 5-325 MG Tablet Take 1-2 po every 6 hours as needed for pain, 7 days, 0 refills
PAST MEDICAL/SURGICAL HISTORY
Arthroscopy Knee - Left.
SOCIAL HISTORY
Behavioral: No tobacco use, not a current smoker, and smoking status: Never smoker.
Alcohol: Alcohol use.
Drug Use: Not using drugs.
Marital: Currently married.
ALLERGIES
• No Known Allergies
FAMILY HISTORY
Family medical history non-contributory
REVIEW OF SYSTEMS
Systemic: No fever, no chills, no recent weight loss, and no recent weight gain.
Head: No headache.
Otolaryngeal: No epistaxis.
Cardiovascular: No chest pain or discomfort, no palpitations, and the heart rate was not fast.
Pulmonary: No dyspnea, no cough, and no wheezing.
Gastrointestinal: No dysphagia and no heartburn. No nausea, no vomiting, and no hematochezia.
Genitourinary: No hematuria and no increase in urinary frequency. No dysuria.
Endocrine: No polydipsia and no excessive sweating.
Hematologic: No easy bleeding and no tendency for easy bruising.
Neurological: No vertigo and no convulsions.
Psychological: No anxiety and no depression.
Skin: No rash and no sore:
PHYSICAL FINDINGS
• Vitals taken 12/04/2015 09:31 am
Height 72 in 65 - 75
Weight 180 lbs 125 - 225
Body Mass Index 24.4 kg/m2
Body Surface Area 2.04 m2
Cervical spine:
-Skin has no obvious lesions to inspection. No pain to palpation.
-ROM intact to flexion, extension, lateral flexion and rotation to the left and right.
-No instability appreciated.
-Strength 5/5. Sensation intact to light touch. No lymphadenopathy or swelling appreciated.
Left Shoulder:
Normal gross appearance without masses. Range of motion full without pain at the extremes of flexion, abduction and internal rotation. Strength 5/5 to resisted external rotation and abduction. Strength 5/5 to internal rotation, forward flexion and extension. No point tenderness to palpation over A.C. joint. No point tenderness over the proximal biceps tendon. Shoulder apprehension negative for instability anteriorly and posteriorly. Distal neuro vascular exam reveals 2+ pulses and intact sensation. No lymph edema appreciated. Deep tendon reflexes 2+.
Right Shoulder:
Normal gross appearance without masses. Range of motion full with mild pain at the extremes of flexion, abduction and internal rotation. Strength 5/5 to resisted external rotation and abduction. Strength 5/5 to internal rotation, forward flexion and extension. Mild tenderness to palpation over A.C. joint. Tenderness to palpation about the proximal biceps tendon. Pain with 90:90 testing. Shoulder apprehension negative. Distal neuro vascular exam intact.
Left wrist:
Full flexion and extension of the wrist. Full radial and ulnar deviation. Full pronation and supination of the forearm. 5 over 5 strength. Negative Tinel's signed. Negative Phalen's test. Full flexion and extension of the fingers and thumb. 5 over 5 strength. Intact sensation to light touch in the median and ulnar nerve distribution. Capillary refill intact.
Right wrist:
Full flexion and extension of the wrist. Full radial and ulnar deviation. Full pronation and supination of the forearm. 5 over 5 strength. Tenderness to palpation over the lateral aspect of the scaphoid. Palpable spur noted. Negative Tinel's signed. Negative Phalen's test. Full flexion and extension of the fingers and thumb. 5 over 5 strength. Intact sensation to light touch in the median and ulnar nerve distribution. Capillary refill intact.
TESTS
X-RAY - 3-view R SHOULDER:
- Bone structures are well mineralize
- No fractures, dislocations, or bone lesions are identified
- Moderate acromioclavicular arthrosis
X-RAY - AP ,Lat , and scaphoid view R wrist
- Bone structures are well mineralized
- No fractures, dislocations, or bone lesions are identified
- Spur off the distal/lateral aspect of the scaphoid. Mild to moderate arthrosis of the radioscaphoid joint
ASSESSMENT
Right shoulder pain
Right proximal biceps tendinitis
Right acromioclavicular arthrosis, primary
Right wrist pain
Right radiocarpal arthrosis, secondary to posttraumatic
Right scaphoid malunion to previously unknown fracture
PLAN
I discussed my findings with the patient. He was educated on his conditions and advised of the treatment options. He was given the opportunity to ask questions and all questions were answered to his satisfaction. In regards to the shoulder I would recommend a cortisone injection over the proximal biceps tendon. As for the wrist I would like him to be seen by our upper extremity specialist. After discussion of potential risks and complications including but not limited to, infection, neural-vascular damage, depigmentation of the skin, rupture of underlying tendons, failure to improve condition and possible worsening of condition, a verbal consent to proceed was obtained.
PROCEDURE:
The skin was prepped with betadine. Ethyl Chloride was topically applied for anesthesia. A 5cc cortisone injection containing equal amounts, 1% Lidocaine, 0.25% Marcaine, and 80 mg Depomedrol was given taking care to avoid inter-tendonous injection. The patient tolerated the procedure well. A bandaid was then applied to the puncture wound.
Ice to involved area
NSAIDs
Follow-up on an as-needed basis for this. He is scheduled for an ACL reconstruction on 12/9/15. The patient's hinged knee brace which she has been wearing since his initial patellar tendon repair on 9/3/15 is quite dirty and odiferous. We will present him with a new brace at this time.
The patient was prescribed a prefabricated brace for the above diagnosis. This was fitted to the patient with manual adjustments including bending, molding, shaping, trimming of straps, hinge adjustments for proper ROM as necessary for the best fit to the patient for comfort and effectiveness. The brace is provided due to weakness and or instability requiring stabilization by semi-rigid or rigid orthosis per the above stated diagnosis.
