mrolf
Guest
Wondering if it is appropriate to code an E&M and 20610
Scenario: CC: Lt shoulder pain. He is a elderly white male who presents with compliants of Lt shoulder pain. He said it really hass been acting up for about the last month. He said it catches when he tries to lift it up. He said he can get it all the way up, but then he has to take his hand to let it down otherwise he has severe sticking type pain in the shoulder. He said he did fall on it years ago and wonders if maybe that was the cause of the problem. He has not taken anything for it.
Lt shoulder: He has excellent range of motion. No significat pain with internal/external rotation. He does have a little bit of pain with the abduction. X-ray of the left shoulder 2-3 views show either calcific tendonities or a bone spur on the underside of the acromion.
A: Lt shoulder pain, likely impingement syndrome.
P. He was given injection of Depo Medrol 8 mg and Maracine 3 cc using sterile technique. He had resolution of the pain. He is to recheck PRN.
Please advise. Thanks.
Scenario: CC: Lt shoulder pain. He is a elderly white male who presents with compliants of Lt shoulder pain. He said it really hass been acting up for about the last month. He said it catches when he tries to lift it up. He said he can get it all the way up, but then he has to take his hand to let it down otherwise he has severe sticking type pain in the shoulder. He said he did fall on it years ago and wonders if maybe that was the cause of the problem. He has not taken anything for it.
Lt shoulder: He has excellent range of motion. No significat pain with internal/external rotation. He does have a little bit of pain with the abduction. X-ray of the left shoulder 2-3 views show either calcific tendonities or a bone spur on the underside of the acromion.
A: Lt shoulder pain, likely impingement syndrome.
P. He was given injection of Depo Medrol 8 mg and Maracine 3 cc using sterile technique. He had resolution of the pain. He is to recheck PRN.
Please advise. Thanks.