99212 or 99213

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Need a refresher and would like someone to audit this visit for a patient that returns for follow up of her left knee pain and MRI results

CC: MRI results of Left Knee

HPI: Orthopedics
Patient comes in for follow up of the left knee. She has no problems and is fully functional. She is doing Yoga and has no pain.

ROS: Review of systems and past medical history reviewed in patient's chart.

ALLERGIES: Penicillin, Amoxicillin, Ampicillin

OBJECTIVE:
General Appearance: WDWN in no acute distress. Alert and oriented
Musculoskeletal: The patient walks with a non-antalgic gait
She has an excellent ROM. No effusion, tenderness or instability
Imaging: MRI of left knee was performed showing arthritic changes

Assessment: Internal Derangement of left knee
Arthritis Left Knee

Plan: We went over the findings. Progress her activities as tolerated.

99212 or 99213
 
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