Needs some guidance on determining what Exam this justify billing for Orthopedics Office level. Trying to see if this qualifies for a comprehensive exam base on Dr
Pulses
RLE pulses: present and palpable
LLE pulses: present and palpable
General
Appearance: well developed, well nourished, in pain
Lymphatic
Nodes: no LE edema
Gait
Inspection: normal
Skin
Appearance: Normal
Lumbar Spine/Pelvis
Range of motion: inc pain w lumbar flexion and limited to 45 deg w pain, dec pain w ext+T
Palpation: + TTP R LS ps
Special Tests
Slump: positive R
IR/ER: negative
SI joint: negative
SLR: positive R
Right Lower Extremity
Range of motion: normal ROM
Musc strength/tone: normal tone and strength, 5-/5 EHL, 4/5 eversion and gastoc
Left Lower Extremity
Range of motion: normal ROM
Musc strength/tone: normal tone and strength
Neurologic
Coordination: normal coordination
Reflexes: 2+, symmetric, no pathological reflexes
Sensation: intact
Mental Status Exam
Orientation: oriented to time, place, and person
Mood and affect: no alteration in mood or affect.
Thanks
msingh23
Pulses
RLE pulses: present and palpable
LLE pulses: present and palpable
General
Appearance: well developed, well nourished, in pain
Lymphatic
Nodes: no LE edema
Gait
Inspection: normal
Skin
Appearance: Normal
Lumbar Spine/Pelvis
Range of motion: inc pain w lumbar flexion and limited to 45 deg w pain, dec pain w ext+T
Palpation: + TTP R LS ps
Special Tests
Slump: positive R
IR/ER: negative
SI joint: negative
SLR: positive R
Right Lower Extremity
Range of motion: normal ROM
Musc strength/tone: normal tone and strength, 5-/5 EHL, 4/5 eversion and gastoc
Left Lower Extremity
Range of motion: normal ROM
Musc strength/tone: normal tone and strength
Neurologic
Coordination: normal coordination
Reflexes: 2+, symmetric, no pathological reflexes
Sensation: intact
Mental Status Exam
Orientation: oriented to time, place, and person
Mood and affect: no alteration in mood or affect.
Thanks
msingh23