Mary, age 51 years, returns to the rheumatology office for a follow-up visit for her diagnosis of rheumatoid arthritis. The physician takes a detailed history and performs an expanded problem-focused exam. The medical decision is of low complexity. During the visit, the patient complains of stiffness and swelling in the left hand, elbows, and neck. The rheumatologist performed an X-ray of the left hand, two views, and reads the results during the visit. Because of the severity of the swelling, the rheumatologist decides to give the patient five trigger-point injections.
How would you code this visit?