Need help, HPI elements for a physical exam

mcarrillo

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Tucson , AZ
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Hi,
I have a doc who did a sports physical on a patient, but I'm not sure how to recognize the elements. Any help appreciated.

New patient. Referred by training staff. A 32-year-old baseball player who throws right and bats right. Presents for preparticipation physical orthopedic exam. Denies any problems with his neck and bilateral upper extremities hips or lower extremities in the past. Denies a history of surgeries. He apparently had only one injury in the past several years when he apparently was struck by a pitched ball and struck his helmet. He may have had a concussion but describes no sequelae from this. Denies any shoulder or right elbow problems. Denies any numbness or tingling.
The symptoms are reported as being none.

Thanks
MCarrillo
 

btadlock1

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Lubbock, TX
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Hi,
I have a doc who did a sports physical on a patient, but I'm not sure how to recognize the elements. Any help appreciated.

New patient. Referred by training staff. A 32-year-old baseball player who throws right and bats right. Presents for preparticipation physical orthopedic exam. Denies any problems with his neck and bilateral upper extremities hips or lower extremities in the past. Denies a history of surgeries. He apparently had only one injury in the past several years when he apparently was struck by a pitched ball and struck his helmet. He may have had a concussion but describes no sequelae from this. Denies any shoulder or right elbow problems. Denies any numbness or tingling.
The symptoms are reported as being none.

Thanks
MCarrillo

This isn't a problem-oriented exam - it's a sports physical. It's probably not payable, but you should check with the payer for specific billling instructions. There's not HPI to count, because there's no 'present illness'. Hope that helps! ;)
 
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