Bernadette10
Guru
Profee coding, ortho clinic. What EM level should be given for this brace fitting? Level 2?
Problem complexity low - 1 acute, uncomplicated problem
Data minimal - 1 x-ray
Risk minimal for the brace
Or - since they want her to come back in 10 days for another x-ray, would this be 2 data elements? I would count the planned x-ray at the future encounter. Is that right?
Also - They had planned to fit the brace 2 days before on 7/12, so is there even medical decision making at this 7/14 visit? I'm thinking yes since they ordered another x-ray and confirmed the brace was fitted correctly.
7/14 note
Patient is here for fitting of a humeral fracture brace. Her pain is under better control now. She rates her pain as 3-8/10 with an average of 4/10, with tingling, skin color changes, hypersensitivity and itching.
2 view x-ray LT humerus shows good positioning of proximal shaft fracture within the brace.
Assessment and Plan: Closed nondisplaced spiral fracture of shaft of LT humerus. Good positioning inside the fracture brace and better tolerance for movement. Follow up in 10 days with pre-clinic x-rays 2 views in the brace.
7/12 note
Patient was getting out of bed when she lost her balance and fell. She was diagnosed with a LT humerus fracture. She has been in a sling since she was seen in the ER on 7/4. X-ray today shows a nondisplaced spiral fracture of the LT humerus shaft.
Assessment and Plan: Closed nondisplaced spiral fracture of shaft of LT humerus. My preference is to treat this in a fracture brace. The brace will be here in 2 days, and she will return then for brace fitting and x-rays in the brace. Hydrocodone 5-325 mg 1 tab po q6h prn pain, 40 tabs was prescribed.
Problem complexity low - 1 acute, uncomplicated problem
Data minimal - 1 x-ray
Risk minimal for the brace
Or - since they want her to come back in 10 days for another x-ray, would this be 2 data elements? I would count the planned x-ray at the future encounter. Is that right?
Also - They had planned to fit the brace 2 days before on 7/12, so is there even medical decision making at this 7/14 visit? I'm thinking yes since they ordered another x-ray and confirmed the brace was fitted correctly.
7/14 note
Patient is here for fitting of a humeral fracture brace. Her pain is under better control now. She rates her pain as 3-8/10 with an average of 4/10, with tingling, skin color changes, hypersensitivity and itching.
2 view x-ray LT humerus shows good positioning of proximal shaft fracture within the brace.
Assessment and Plan: Closed nondisplaced spiral fracture of shaft of LT humerus. Good positioning inside the fracture brace and better tolerance for movement. Follow up in 10 days with pre-clinic x-rays 2 views in the brace.
7/12 note
Patient was getting out of bed when she lost her balance and fell. She was diagnosed with a LT humerus fracture. She has been in a sling since she was seen in the ER on 7/4. X-ray today shows a nondisplaced spiral fracture of the LT humerus shaft.
Assessment and Plan: Closed nondisplaced spiral fracture of shaft of LT humerus. My preference is to treat this in a fracture brace. The brace will be here in 2 days, and she will return then for brace fitting and x-rays in the brace. Hydrocodone 5-325 mg 1 tab po q6h prn pain, 40 tabs was prescribed.