I'm uncertain whether to code sequela of fracture or just pain code (provider's dx) for this encounter. Does the provider need to clearly state that the pain is a result of an injury to use the sequela code, or is the information below enough to support that it is (or am I making an assumption)? Note as follows:
Pt with a history of pelvic bone and left hip fractures sustained in MVA in 2008, status post surgical correction with hardware, who now presents with complaint of left hip and ankle pain. She has been putting off having this evaluated because she's been busy with school and moving. States that left ankle is now occasionally swelling and becoming tender. States when she walks, it feels uneven and relates this as to why her ankle is now hurting. She denies any recent trauma or injury. States that she notices the symptoms primarily at the end of the day. She denies any excessive activity or exercise. Takes Advil PRN for pain.
Exam: Musculoskeletal: LLE is approximately an inch shorter than RLE in comparison with patient lying supine. Good ROM of L hip despite pain. L ankle with tenderness to palpation over lateral, posterior aspect. Good ROM but only 3/5 strength against resistance to dorsiflexion, plantar flexion.
Assessment: Hip pain, ankle joint pain.
-will X-ray pelvis, L hip and L ankle
-patient would benefit from heel lift vs shoe insert for ambulation due to uneven distribution of extremities
-Orthopedic referral
-Ibuprofen 800mg PO q 8 hrs PRN pain with food.
What is the most appropriate diagnosis for this encounter?
Thank you for your help!
Pt with a history of pelvic bone and left hip fractures sustained in MVA in 2008, status post surgical correction with hardware, who now presents with complaint of left hip and ankle pain. She has been putting off having this evaluated because she's been busy with school and moving. States that left ankle is now occasionally swelling and becoming tender. States when she walks, it feels uneven and relates this as to why her ankle is now hurting. She denies any recent trauma or injury. States that she notices the symptoms primarily at the end of the day. She denies any excessive activity or exercise. Takes Advil PRN for pain.
Exam: Musculoskeletal: LLE is approximately an inch shorter than RLE in comparison with patient lying supine. Good ROM of L hip despite pain. L ankle with tenderness to palpation over lateral, posterior aspect. Good ROM but only 3/5 strength against resistance to dorsiflexion, plantar flexion.
Assessment: Hip pain, ankle joint pain.
-will X-ray pelvis, L hip and L ankle
-patient would benefit from heel lift vs shoe insert for ambulation due to uneven distribution of extremities
-Orthopedic referral
-Ibuprofen 800mg PO q 8 hrs PRN pain with food.
What is the most appropriate diagnosis for this encounter?
Thank you for your help!
