A 50-year-old established female patient with osteoporosis comes to the office for her monthly ibandronate sodium injection. While there, the patient reports she has had increased low back pain and stiffness for the past three weeks, which is interfering with her recreational activities and ability to perform household chores that require bending and lifting and has seen little relief with ibuprofen. The patient denies any other musculoskeletal pain and denies any joint swelling. The patient is on indomethacin and folic acid.
The rheumatologist performs a problem-focused exam. The musculoskeletal exam reveals flattening of lumbar curve with decreased lumbar flexion and bilateral SI joint tenderness on palpation. Routine labs are ordered, and the patient will continue her other medications. The patient then receives a three-milligram ibandronate sodium injection prior to leaving the office.
How would you code this?