only use the 1995 guidelines

daniel

True Blue
Messages
535
Best answers
0
what level do you get out of this.


Pt complaining of persistent low back pain radiating to legs.
States Physical Therapy is helpful, takes Advil prn for pain.


PE: Gait is slight shuffling in nature. On lumbosacral spine examination, there is marked decreased in
range of motion and extension at 10 to 20 degrees. There is spasm in the lumbar paraspinal muscles and
trigger point area is noted.


IMPRESSION: Lumbar radiculopathy, lumbar spinal stenosis, and myofascial pain. Continue Advil
every six hours as needed, and continue PT. Return for F/U visit in two-three months unless something
develops before that.
Follow-up



Thank You
Daniel
CPC.


Just seeing where the E/M coding world opion is at, you know. Checking which way the wind is blowing. To make sure I'm going in the right direction.
 
Top