A 46-year-old male with osteoarthritis of his right knee comes in for a routine follow-up office visit. The patient had an intraarticular corticosteroid injection in his right knee six weeks ago with reported improvement in knee pain and stiffness. The patient reports stiffness in the knee lasting five to 10 minutes after long car rides and in the morning, one to two times per week, and reports mild knee pain when climbing stairs. The patient also reports that his mood has greatly improved since the decrease in his knee pain, and he has no other complaints or comorbidities. He is currently taking etodoloc and ranitidine, as needed.
On examination, the patient has normal vital signs. His height is 5’10”, he weighs 190 pounds, his body mass index is 27.3, and his lungs are clear. His heart has a regular rate and rhythm, with no murmurs or friction rubs. The patient’s abdomen is soft and nontender, with no mass or hepatosplenomegaly. His right knee has crepitus and mild tenderness on extreme flexion, but no warmth or effusion. His left knee is unremarkable, with full range of motion and no tenderness.
Diagnosis: Osteoarthritis right knee; clinically stable.
Plan: The patient is given prescriptions to continue etodolac and ranitidine. He is counseled regarding the benefits of daily exercise and weight loss in the management of osteoarthritis. Ways to incorporate daily physical activity into the patient’s schedule are discussed, along with recommendations to reduce fat and caloric intake. The patient is asked to return in four months for a follow-up appointment, sooner if problems arise.
How should this encounter be coded?