Case #13 Winner, Answer Key, & Rationale

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Best answers
Lindsay K. won case #13. See below for the answer key and rationale.

CPT: 99214, 20610 or 99214, 20610, 20610
CPT Modifiers: 25, 50 or 25, RT, LT
ICD-9: 726.13, 531.90

CPT: 99214-25, 20610-50

The provider performed: Detailed history (extended HPI, extended ROS, pertinent PFSH), Expanded Problem Focused exam (limited 2-7 systems), Moderate MDM (3 points (one stable established condition and one worsening), 1 data point, moderate risk). The joint injection is performed without imaging guidance.

Steps to look up: Established/Patient/Office Visit; Injection/Joint. Modifier 25 is appended for significant and separately identifiable E/M. Modifier 50 is reported for the injection performed on the left and right shoulders. This can also be reported using modifier RT and LT.

ICD-9-CM: 726.13, 531.90

In the history portion of the document, the rotator cuff tear is described as partial. The stomach ulcer is coded because it is documented in the plan as contributing to the change in the pain medication.

The supply code for the Depo-medrol is coded with J1040. We did not require the code for the supply to get the correct answer. A supply code for bupivacaine is not reported. Local anesthetic is included in the global package for the procedure.

Steps for look up: Tear, torn/rotator cuff/nontraumatic/partial; Ulcer/stomach/without mention of obstruction (fifth digit).

In the history, it states the patient has neck pain and back pain that is caused by the degenerative disease. Additional diagnosis codes which were given credit include 722.4 and 722.52. In the plan it states pain but doesn’t specific pain so if the additional diagnosis codes were not reported it did not affect the score. The knee osteoarthritis is mentioned in the history but not documented as part of the plan or assessment.
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I am wondering why the ulcer was coded as the physician reports the endoscopy was negative for wondering why the hx of code then would not have been used for this situation.

Thanks Maureen

You are correct. The HCPCS code J1040 is also apart of the set for the case. Our webmaster missed this when posting the answer key on the website so we're giving credit if you got everything else right.

Case # 13 clinical added for Answer key & Rationale

Case # 13 clinical added for Answer key & Rationale
Since the clinical info wasn't included in posting of answer & rationale; and the link to case clinical info given now is not accessible (error page shows up) .... I thought it wise to include the missing clinical info.

Hint: This case #13 reviews the documentation very pleasant 78 year old woman and his follow-up bilateral shoulder rotator cuff problems as well as other pain including neck, lower back. Modifiers and a detailed look up tool will come in handy for this one!

Case #13

CHIEF COMPLAINT: Follow-up bilateral shoulder rotator cuff problems as well as other pain including neck, low back.

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 78-year-old female with known history of degenerative disease in her lumbar spine from osteoarthritis of the knees and more recently difficulties with the shoulders. While the plain X-ray of the left shoulder has shown a lytic defect in the humerus, this was not confirmed on her MRI felt to be a benign finding. The MRI of the left shoulder showed degenerative partial tearing of the rotator cuff as well as some degenerative change. We have not obtained an MRI of the right shoulder. Patient also notes increased pain in her neck and low back where she has known degenerative change. I have given her a cortisone injections at last visit in the shoulders. She noted the left one helped a lot but the right one did seem to help too much. She is interested in doing some physical therapy for the shoulders again. She knows that her pain vary somewhat with weather changes. She reminds me that she did have some gastric ulceration from Aleve. Recent endoscopy has been negative. She is on Nexium. She has been taking Darvocet for pain which is helpful to a degree. She describes some nocturnal shakiness potentially could be from the Darvocet.

CURRENT MEDICATIONS: Darvocet prn pain.

REVIEW OF SYSTEMS: Review of systems form reviewed with the patient and is positive for what is noted above, pain level 8/10, occasional sweats at night, sense of weakness, some dry mouth and eyes.

OBJECTIVE: VS- Per flow sheet Wt 158

General: NAD

Eyes: Externally clear.

Musculoskeletal: She is able to abduct the shoulders fairly well. Some pain and mild weakness with resisted supraspinatus testing on the right shoulder.

Spine: Some lower lumbar tenderness, worse with forward flexion


1. Bilateral rotator cuff degenerative tear

2. Gastric ulcer


1. Discussed with the patient. At this point, I think it would be safe to try some salsalate 500 mg one to two up to twice daily as needed for pain, since this is a much less irritating agent on the stomach and she is now on Nexium. Since her pain also seems somewhat uncontrolled, will try Vicodin one tablet 3 times a day instead of the Darvocet. She will stop the Darvocet.

2. For her shoulders, I will send her back to physical therapy and I did agree to do a repeat bilateral subacromial cortisone injections. Both were prepped in a sterile fashion and after verbal consent injected with 80 mg of Depo-Medrol and 4 cc of bupivacaine. She tolerated these well.

3. She will follow-up with me on an as-needed basis.