taylov519
Contributor
Need a second pair of eyes, WC changed the code from 99203 to 99202. What do you get?
Here is the chart note:
51-year-old male who works for a utility district and does a lot of opening and closing of water valves. This patient was doing this repetitively about a month and a half ago and he began to experience right shoulder pain. The pain has persisted and is worse when he tries to reach above shoulder level or reach behind him. He denies paresthesias or paralysis. No neck pain. He had no shoulder problems in the past. He has gone through three visits of physical therapy at this point without much pain relief.
PAST MEDICAL HISTORY:
See medical questionnaire in the chart.
PHYSICAL EXAMINATION:
The right shoulder presents with no swelling or gross deformity. He has full active range of motion of the shoulder which is symmetric with the left. He is tender to palpation in the subacromial space laterally with deep palpation, and he had positive impingement signs. There is no anterior apprehension. The patient has 5/5 strength around the shoulder and a normal sensory exam in the right upper extremity.
PROCEDURE:
A PARQ conference was held before a mixture of LIDOCAINE, MARCAINE, and DEPO-MEDROL was injected into the subacromial space of the right shoulder, giving this patient excellent pain relief shortly after the injection.
IMPRESSION:
Impingement, right shoulder.
PLAN:
Subacromial steroid injection as noted above and physical therapy for rotator cuff strengthening. I will see the patient back in the clinic in a month for reevaluation. I will keep him on limited duties at work until that time.
APRIL 27, 2010
X-RAYS:
Outside radiographs as well as radiographs taken today of the right shoulder on this patient show some mild acromioclavicular hypertrophy and a type I to II acromion, but are otherwise unremarkable.
Here is the chart note:
51-year-old male who works for a utility district and does a lot of opening and closing of water valves. This patient was doing this repetitively about a month and a half ago and he began to experience right shoulder pain. The pain has persisted and is worse when he tries to reach above shoulder level or reach behind him. He denies paresthesias or paralysis. No neck pain. He had no shoulder problems in the past. He has gone through three visits of physical therapy at this point without much pain relief.
PAST MEDICAL HISTORY:
See medical questionnaire in the chart.
PHYSICAL EXAMINATION:
The right shoulder presents with no swelling or gross deformity. He has full active range of motion of the shoulder which is symmetric with the left. He is tender to palpation in the subacromial space laterally with deep palpation, and he had positive impingement signs. There is no anterior apprehension. The patient has 5/5 strength around the shoulder and a normal sensory exam in the right upper extremity.
PROCEDURE:
A PARQ conference was held before a mixture of LIDOCAINE, MARCAINE, and DEPO-MEDROL was injected into the subacromial space of the right shoulder, giving this patient excellent pain relief shortly after the injection.
IMPRESSION:
Impingement, right shoulder.
PLAN:
Subacromial steroid injection as noted above and physical therapy for rotator cuff strengthening. I will see the patient back in the clinic in a month for reevaluation. I will keep him on limited duties at work until that time.
APRIL 27, 2010
X-RAYS:
Outside radiographs as well as radiographs taken today of the right shoulder on this patient show some mild acromioclavicular hypertrophy and a type I to II acromion, but are otherwise unremarkable.
