Blackhorse
Guru
Physical Exam
General: The patient is healthy-appearing and of the stated age. Psych: Alert and oriented, no acute distress Head: Normocephalic and atraumatic Eyes: Anicteric pupils symmetric, extraocular muscles intact
Exam of the left knee reveals a superficial abrasion at the anteromedial aspect of the knee with no erythema, drainage, or sign of infection. There is tenderness to palpation at the inferolateral aspect of the patella. There is also tenderness of the hamstring tendons medially. She has fairly comfortable range of motion within 0-70°. There is no gross instability. Calf is soft and nontender. Homans sign is negative. Peripheral vascular exam is grossly intact distally. Neurologic exam is grossly intact distally.
Diagnostic Studies
AP, lateral, and oblique view x-rays as well as a sunrise view x-ray taken at ABC Emergency were reviewed in detail. These demonstrate a minimally displaced fracture at the inferior medial aspect of the patella with approximately 1 mm of displacement. No other pathology noted.
Impression
#1: Left knee minimally displaced patella fracture. Date of injury: 10/25/2017.
#2: Left medial hamstring strain.
Plan/Recommendation
I had a lengthy discussion with the patient regarding the diagnosis and treatment alternatives.
I recommended immobilization in a T ROM brace. The patient was provided with this brace. She will keep the brace locked in full extension at all times. I recommended elevation and ankle pumps for circulation. She may remove the brace for showering. She may weight-bear as tolerated while wearing the brace locked in full extension. She may ice and take over-the-counter anti-inflammatories as needed.
Follow-up in one week for reexamination with new AP and sunrise view x-rays of the left knee.
Per the above Diagnostic Study, can doctor bill 76140?
Thank you.
Blackhorse, CPC_A
General: The patient is healthy-appearing and of the stated age. Psych: Alert and oriented, no acute distress Head: Normocephalic and atraumatic Eyes: Anicteric pupils symmetric, extraocular muscles intact
Exam of the left knee reveals a superficial abrasion at the anteromedial aspect of the knee with no erythema, drainage, or sign of infection. There is tenderness to palpation at the inferolateral aspect of the patella. There is also tenderness of the hamstring tendons medially. She has fairly comfortable range of motion within 0-70°. There is no gross instability. Calf is soft and nontender. Homans sign is negative. Peripheral vascular exam is grossly intact distally. Neurologic exam is grossly intact distally.
Diagnostic Studies
AP, lateral, and oblique view x-rays as well as a sunrise view x-ray taken at ABC Emergency were reviewed in detail. These demonstrate a minimally displaced fracture at the inferior medial aspect of the patella with approximately 1 mm of displacement. No other pathology noted.
Impression
#1: Left knee minimally displaced patella fracture. Date of injury: 10/25/2017.
#2: Left medial hamstring strain.
Plan/Recommendation
I had a lengthy discussion with the patient regarding the diagnosis and treatment alternatives.
I recommended immobilization in a T ROM brace. The patient was provided with this brace. She will keep the brace locked in full extension at all times. I recommended elevation and ankle pumps for circulation. She may remove the brace for showering. She may weight-bear as tolerated while wearing the brace locked in full extension. She may ice and take over-the-counter anti-inflammatories as needed.
Follow-up in one week for reexamination with new AP and sunrise view x-rays of the left knee.
Per the above Diagnostic Study, can doctor bill 76140?
Thank you.
Blackhorse, CPC_A
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