ortho1991
Guru
Hi All, I'm hoping someone can help with this debate. What is the correct level of this office note 99213 or 99214? Pt was last seen over a year ago.
Patient Evaluation
Seen in our office today for LT knee pain. She has a history of a RT knee ACL reconstruction with autograft bock in 2016.
History of Present Illness: pt states that she was playing in her lacrosse game this past Monday, when she planted her LT foot pivoted, felt a pop, had immediate onset of pain and swelling, was not able to continue playing. It continued to bother and continued to be swollen. She feels like her knee will give out on her when she weight bears. She is here today for evaluation of this.
Past medical history, past surgical history, medication, drug allergies, review of systems, family history and social history are documented on the intake form and reviewed with the pt today.
PE: On physical examination, pt is in no acute distress. On inspection of the patient's LT knee skin is intact. She has 1 to 2+ effusion of the knee. No tenderness to palpation in medial and lateral joint lines. Extension only to about 5 degrees, flexion ot 901. Stable to valgus stress testing, but she has appositive anterior drawer. Positive Lachman test. Negative posterior drawer. Neurovascularly intact in LT lower extremity.
Diagnostic Studies: X-ray taken in the office today to include 3 views of LT knee, AP, lateral and sunrise views that demonstrate no evidence of fracture, dislocation, or soft tissue changes.
Impress: LT knee pain, swelling, and instability consistent with anterior cruciate ligament rupture.
Plan" I had a discussion today with the patient of her physical exam finding and diagnostic studies. At this point, I have recommended getting into a hinged knee brace for stability to protect the knee, getting started on a course of physical therapy to get range of motion back. We will also get an MRI of the LT knee, to confirm a ACL rupture.
Your thoughts will be appreciated.
Patient Evaluation
Seen in our office today for LT knee pain. She has a history of a RT knee ACL reconstruction with autograft bock in 2016.
History of Present Illness: pt states that she was playing in her lacrosse game this past Monday, when she planted her LT foot pivoted, felt a pop, had immediate onset of pain and swelling, was not able to continue playing. It continued to bother and continued to be swollen. She feels like her knee will give out on her when she weight bears. She is here today for evaluation of this.
Past medical history, past surgical history, medication, drug allergies, review of systems, family history and social history are documented on the intake form and reviewed with the pt today.
PE: On physical examination, pt is in no acute distress. On inspection of the patient's LT knee skin is intact. She has 1 to 2+ effusion of the knee. No tenderness to palpation in medial and lateral joint lines. Extension only to about 5 degrees, flexion ot 901. Stable to valgus stress testing, but she has appositive anterior drawer. Positive Lachman test. Negative posterior drawer. Neurovascularly intact in LT lower extremity.
Diagnostic Studies: X-ray taken in the office today to include 3 views of LT knee, AP, lateral and sunrise views that demonstrate no evidence of fracture, dislocation, or soft tissue changes.
Impress: LT knee pain, swelling, and instability consistent with anterior cruciate ligament rupture.
Plan" I had a discussion today with the patient of her physical exam finding and diagnostic studies. At this point, I have recommended getting into a hinged knee brace for stability to protect the knee, getting started on a course of physical therapy to get range of motion back. We will also get an MRI of the LT knee, to confirm a ACL rupture.
Your thoughts will be appreciated.