Combining ICD 10 dx codes

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Thank you in advance for taking the time to review this.

I received a report that has the following documentation and coding. Im thinking that not only is it poor documentation but that the codes are not supported by this long winded write up. I am looking for input as to how you would code this.

History of Present Illness
Back Pain / Bilateral Leg Pain
The patient complains of pain in the Whole spine . From neck to sacrum The patient has been experiencing this pain for 4 years. He reports onset of pain gradually over time . The patient describes his pain as constant aching, tightness, stiffness and soreness . The patient also has pain that is constant tingling and electrical . The pain radiates to the bilateral upper extremity and bilateral lower extremity. Right now he describes his pain as 8/10 on a pain scale of 0-10. 10/10 without medication The pain is made worse by bending, changing position, heat, increased activity, lifting, sitting a long time, turning side to side, stooping, pulling, pushing, pressure, getting up from a seated position, repetitive movements, weather changes and reaching. His pain gets better by changing position, lying flat, taking medications and resting. Other associated symptoms/problems are as follows: frustrated because of pain, non-restful sleep, numbness and tingling . There is no history of vertigo / dizziness. Patient denies any recent history of falls. There is no history of fibromyalgia. Professional caregivers seen in the past include pain medicine physician, family physician, general practitioner, general surgeon and podiatrist. The following tests have been done in the past: X-rays and MRI scan . He has tried and failed following medications in the past. Butrans not effective Patient reports to clinic for routine follow up to review recent LCMS results and medication refill. Patient states that he has been doing good since he is now working and feels that it is a better enviroment for him. Patients states he has a pain level of 8/10 back pain that radiates to his lower legs and mostly because he is working in construction. Patient continues to use the Norco to decrease the severity of pain, while the pain is never totally abated, the current dose and frequency allow for increased mobility and function. Upon questioning patient denies side effects such as bowel / bladder incontinence or adverse reactions such as euphoria /dysphoria or sexual dysfunction at this time.

Review of Systems: Musculoskeletal: Reports muscle pain or tenderness, muscle cramp, neck pain, back pain, joint pain, joint stiffness, joint swelling, morning stiffness, atrophy and posture abnormalities. Denies muscle twitches, muscle wasting, muscle weakness, loss of muscle bulk, shoulder pain and night cramps. Joint abnormality reported. Reports limitation of joint movement. No history of fractures. He complains of osteoarthritis.

MUSCULOSKELETAL: Cervical range of motion is decreased. Lateralization: Right and left lateralization is 45 degree. Spurling's test is negative bilaterally. *Shoulder range of motion is 0 to 180 degree in abduction and flexion in both passive and active planes without evidence of impingement or limitation with internal rotation 70 degree and external rotation 90 degree bilaterally. Scapular motion is full in both protraction and retraction. Impingement test is negative bilaterally. *Elbow range of motion is intact bilaterally with flexion 150 degree and extension 0 degree. Hyperabduction, costoclavicular, and Adson's are negative bilaterally. *Wrist range of motion is intact bilaterally with flexion 80 degree and extension 70 degree. Ulnar and radial deviation is 20 degree and 30 degree bilaterally and respectively. Tinel's tap test is negative bilaterally. Phalen's compression test is negative bilaterally. Finkelstein's test is negative bilaterally. *Visual inspection shows no evidence of pelvic obliquity. *Lumbar extension is at 25 degree. Lumbar range of motion is normal with flexion 90 degree Lateralization is: Right and left lateralization is normal at 30 degree. Rotation is: Right and left rotation is normal at 45 degree. Straight leg raising test is negative bilaterally. *Sacroiliac distraction test is negative bilaterally. Piriformis provocation test is negative bilaterally. Hip flexion is intact with flexion being at 120 degree bilaterally. Extension is intact and is 0 degree. *Knee flexion is intact bilaterally and being 130 degree and 20 degree. Ankle range of motion is intact bilaterally with plantar flexion 60 degree. And dorsiflexion 20 degree.


Assessment and Plan
ICD: Cervical radiculitis (M54.12)
ICD: Cervical spondylosis (M47.812)
ICD: Cervical spinal stenosis (M48.02)
ICD: Facet arthritis of cervical region (M46.92)
ICD: Thoracic disc herniation (M51.24)
ICD: Facet arthritis of lumbar region (M47.816)
ICD: Lumbar canal stenosis (M48.06)
ICD: Lumbar radiculitis (M54.16)
ICD: Lumbosacral plexus lesion (G54.1)
ICD: Spondylolisthesis at L4-L5 level (M43.16)
ICD: Spondylolisthesis at L5-S1 level (M43.17)
ICD: Tobacco dependence (F17.200)
ICD: Opioid dependence, continuous (F11.20)

Sorry that it is so long :(

Kim
 
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