A 72-year-old female patient returns to the office for a routine follow-up visit for osteoarthritis. The patient reports that her right knee has been more swollen and stiff in the past three weeks. She is currently on celecoxib and ranitidine. The patient also mentioned that she has been having abdominal pain and nausea after she takes the celecoxib. The rheumatologist takes a detailed history from the patient. On examination, the patient is alert and oriented. Her vital signs are normal, her height is 5’7”, her weight is 140 pounds, and her temperature is 98º. Her head, eyes, ears, nose, and throat exam was normal. There was no lymphadenopathy. Her lungs were clear. Her heart was at a regular rate and rhythm, no murmurs or friction rubs, and there were good peripheral pulses. Her abdomen was soft and nontender with no mass or holo-systolic murmurs.
The patient’s physical examination is remarkable for a large effusion of the right knee. After performing a diagnostic ultrasound of the right knee—which included the examination of the muscle, tendon, and joint of the knee—the physician makes the decision to perform an aspiration of the right knee. The physician explains therapeutic options to the patient, including risks and benefits, and performs an aspiration of the right knee with a 10 ml Synvisc One injection. The patient is taken off of celecoxib. A new prescription for the pain is prescribed, and the patient is given discharge instructions on postarthrocentesis care and follow-up.
How would you code this visit?
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