Wiki Does this note justify E&M and adjustment

[kzcoder]

Hi,

I am wondering if the following note for a subsequent visit would justify an E&M and an adjustment of 2 regions. I would appreciate any assistance on the CPT and I-9 coding.

Thanks

presents
for: neck and arm burning that is better than before she started care.


Patient reports feeling Better.

OBJECTIVE:
OBSERVATION:right shoulder high.

PAIN: 2/10
SENSATION: burning

PALPATION: T2-5 C4-7 c1 were fixated and have decreased range of motion.
ACTIVE RANGE OF MOTION CERVICAL:
Flexion: WNL
Extension: 70% motion available
Right Rot: 90% motion available
Left Rot: 70% motion available
Right SB: 65% motion available
Left SB: 65% motion available
ACTIVE RANGE OF MOTION LUMBAR:
Flexion: WNL
Extension: WNL
Right Rot: WNL
Left Rot: WNL
Right SB: WNL
Left SB: WNL
------------------------------ IMPRESSION -------------------------------
Diagnosis:
1) Pain In Thoracic Spine [P]
2) Nonallopathic Lesions, Cervical Region
3) Nonallopathic Lesions, Thoracic Region
4) Backache, Unspecified
5) Nonallopathic Lesions, Pelvic Region
--------------------------------- PLAN ----------------------------------

Change visit frequency

re exam was performed today and the patient will be changed to two
adjustements a month for 8 adjustments. T2-5 C4-7 c1 were adjusted today.


Return to Chiropractic Clinic 01-Apr-2014

Following education topics discussed with patient:

No Patient Education Found
No Patient Education Found

 

[ejlehman]

Definitely 2 regions. I would probably bill a low level exam.