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Level Estatablished Pt Visit?

  1. #1
    Default Level Estatablished Pt Visit?
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    The patient comes in today for evaluation regarding the right hip. He reports that he has tried to go back to work over the last week, but has been unable to due to continued pain at the lateral aspect of the hip and a limp.

    PHYSICAL EXAMINATION: On physical exam the patient is an alert, awake, and appropriate man in no acute distress. He is able to ambulate with a cane, but is indeed tender at the greater trochanter. He is able to abduct and forward elevate, but with pain.

    RADIOGRAPHS: X-rays are reviewed that were done last visit, four days ago. Those reveal a periprosthetic right hip fracture, a fracture at the tip of the greater trochanter at an area of heterotrophic ossification without displacement. The prosthesis itself is nondisplaced.

    IMPRESSION: The patient should not work for the next two weeks and then be reevaluated.

    PLAN: The prognosis is guarded. If nonhealing occurs, excision and possible repair of the abductor mechanism may be necessary.

  2. #2
    I am not expert. But I feel 99213 is OK

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