Challenge: Mary, age 51, comes in for a follow-up visit for her fibromyalgia diagnosis. The physician does an examination including a review of symptoms, takes a history of the illness, and makes a medical decision of moderate complexity. During the visit, the patient complains of pain in the trapezius muscle, shoulders, and hips. Because of the severity of the pain, the physician decides to give the patient three trigger-point injections. How do you code this?
Explore This IssueMarch 2007
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