MrsB
Guest
Here's my example for practice.
Date of service: 13 Jan 2020
Chief complaint
CC: chronic right shoulder pain
HPI
Pt is a 24 y/o male who is in the orthopedic clinic today 13 Jan 2020 for right shoulder steroid injection.
He had been evaluated by Dr. XYZ for possible impingement syndrome and he recommended steroid injection. Pt does complain of overhead and behind his back activities that cause slight increase in his pain.
ROS
Gen: no recent fever/chills/malaise
HEENT: no loss of vision, no nasal discharge, no ear pain
CV: no chest pain, no palpitations, no hx of HTN/CAD
Respiratory: no cough, SOB or wheezing
Neurological: no numbness, weakness or tremors in upper or lower extremities
Skin: no skin lesions, rashes or open wounds
Musculoskeletal: pain right shoulder with stiffness with movement, all other extremities no complaints
PE
Gen: well developed, well nourished, no acute distress
Cardiovascular: Radial pulses strong bilaterally, capillary refill brisk
Skin: no signs of infection, no ecchymosis, no erythema
Musculoskeletal: right shoulder= pain 6/10, tenderness with movement, biceps tendon palpable in the bicipital groove, no defect noted in the bicep muscle. Negative crossover and equivocal O’Brien.
Negative Jobe test.
Neuro: sensation intact to light touch overall distributions, motor function intact
Psych: normal mood, attitude, appropriate
A/P
Chronic right shoulder pain, tenatively, Impingement syndrome of right shoulder:
Patient was given a steroid injection in his right shoulder today.
TIME OUT performed. Confirmed correct patient, site, procedure. The patient positioned correctly for the procedure. All necessary equipment available. The right shoulder was prepped in the usual sterile fashion. A posterior approach was used. The subacromial space was infiltrated with a mixture of 1 mL 1% lidocaine without epinephrine, 1 mL 0.5% bipivcaine and 40 mg Kenalog (LOT# XXXXX Exp: 01/2021).
Patient tolerated this procedure well. Patient remained in the clinic afterwards and no complications were observed. The patient was advised on standard precautions along with signs and symptoms of infection and recommendations of avoid any strenuous activities for 24 hours.
Signed; ABCD, PA
So is there any hints/information given that I should start coding for an E/M first? I am having trouble with this as I have a habit of looking for an E/M code first before coding for diagnoses and procedures. Thanks.
Date of service: 13 Jan 2020
Chief complaint
CC: chronic right shoulder pain
HPI
Pt is a 24 y/o male who is in the orthopedic clinic today 13 Jan 2020 for right shoulder steroid injection.
He had been evaluated by Dr. XYZ for possible impingement syndrome and he recommended steroid injection. Pt does complain of overhead and behind his back activities that cause slight increase in his pain.
ROS
Gen: no recent fever/chills/malaise
HEENT: no loss of vision, no nasal discharge, no ear pain
CV: no chest pain, no palpitations, no hx of HTN/CAD
Respiratory: no cough, SOB or wheezing
Neurological: no numbness, weakness or tremors in upper or lower extremities
Skin: no skin lesions, rashes or open wounds
Musculoskeletal: pain right shoulder with stiffness with movement, all other extremities no complaints
PE
Gen: well developed, well nourished, no acute distress
Cardiovascular: Radial pulses strong bilaterally, capillary refill brisk
Skin: no signs of infection, no ecchymosis, no erythema
Musculoskeletal: right shoulder= pain 6/10, tenderness with movement, biceps tendon palpable in the bicipital groove, no defect noted in the bicep muscle. Negative crossover and equivocal O’Brien.
Negative Jobe test.
Neuro: sensation intact to light touch overall distributions, motor function intact
Psych: normal mood, attitude, appropriate
A/P
Chronic right shoulder pain, tenatively, Impingement syndrome of right shoulder:
Patient was given a steroid injection in his right shoulder today.
TIME OUT performed. Confirmed correct patient, site, procedure. The patient positioned correctly for the procedure. All necessary equipment available. The right shoulder was prepped in the usual sterile fashion. A posterior approach was used. The subacromial space was infiltrated with a mixture of 1 mL 1% lidocaine without epinephrine, 1 mL 0.5% bipivcaine and 40 mg Kenalog (LOT# XXXXX Exp: 01/2021).
Patient tolerated this procedure well. Patient remained in the clinic afterwards and no complications were observed. The patient was advised on standard precautions along with signs and symptoms of infection and recommendations of avoid any strenuous activities for 24 hours.
Signed; ABCD, PA
So is there any hints/information given that I should start coding for an E/M first? I am having trouble with this as I have a habit of looking for an E/M code first before coding for diagnoses and procedures. Thanks.