risnerclan
Networker
I want to post this office visit out and would like some input on how you would code this level of E/M.
Thanks!
CHIEF COMPLAINT:
Follow-up, low back pain.
HISTORY OF PRESENT ILLNESS:
His symptoms have improved with rest and physical therapy. He has had his MRI scan. The Aleve is helping. He has not returned to basketball.
SYSTEM REVIEW:
Neuro: Transient tingling in the left lower extremity.
GI/GU: No change in bowel or bladder habits.
Constitutional: No fever, chills, night sweats, or unintended weight loss.
MRI:
The MRI report showed degenerative disk disease at L4-L5, L5-S1 with a mild to moderate broad-based posterior exophyte and left paracentral disk herniation featuring inferior migration along the L4 vertebral body. There was also central canal stenosis, lateral recess stenosis, but no foraminal stenosis at this level. There was also a herniation at L5-S1.
His left hip MRI scan was interpreted as normal without evidence of avascular necrosis or slipped capital femoral epiphysis. No obvious sign of labral tear.
IMPRESSION:
Two-level disk herniations.
PLAN:
1. Continue to withhold from basketball.
2. Sterapred DS, 12-day Dosepak.
3. Physical therapy.
4. Recheck in 2-3 weeks and if not improved then consider lumbar epidural steroid injections.
Thanks!
CHIEF COMPLAINT:
Follow-up, low back pain.
HISTORY OF PRESENT ILLNESS:
His symptoms have improved with rest and physical therapy. He has had his MRI scan. The Aleve is helping. He has not returned to basketball.
SYSTEM REVIEW:
Neuro: Transient tingling in the left lower extremity.
GI/GU: No change in bowel or bladder habits.
Constitutional: No fever, chills, night sweats, or unintended weight loss.
MRI:
The MRI report showed degenerative disk disease at L4-L5, L5-S1 with a mild to moderate broad-based posterior exophyte and left paracentral disk herniation featuring inferior migration along the L4 vertebral body. There was also central canal stenosis, lateral recess stenosis, but no foraminal stenosis at this level. There was also a herniation at L5-S1.
His left hip MRI scan was interpreted as normal without evidence of avascular necrosis or slipped capital femoral epiphysis. No obvious sign of labral tear.
IMPRESSION:
Two-level disk herniations.
PLAN:
1. Continue to withhold from basketball.
2. Sterapred DS, 12-day Dosepak.
3. Physical therapy.
4. Recheck in 2-3 weeks and if not improved then consider lumbar epidural steroid injections.