On January 11, 2010, a 68-year-old female returns to the office for her monthly abatacept infusion treatment; she has an established diagnosis of moderate rheumatoid arthritis. She is currently on a nonsteroidal antiinflammatory drug and also takes glucosamine-chondroitin. She reports pain, stiffness, and swelling in both knees. She states that her pain is a six on a scale of one to 10. She denies any other complaints.
On exam, she is alert and oriented, her vital signs are normal, and there is no lymphadenopathy. Her lungs are clear, and she has a regular heart rate and rhythm with no murmurs or friction rubs. Her abdomen is soft with epigastric tenderness on palpation. There are no masses or hepatosplenomegaly. The musculoskeletal exam shows bony proliferation and crepitus in the right knee and irritability, large effusion, warmth, and decreased flexion in the left knee without erythema. All other joints are unremarkable, with full range of motion.
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After the therapeutic options are discussed with the patient, the infusion is performed. The patient is infused with 750 mg of abatacept for a total of 29 minutes. The patient’s medication is left unchanged. A complete blood count and an MRI of the knee are ordered.
This is the first Medicare patient qualifying for Physician Quality Reporting Initiative (PQRI) reporting. The rheumatologist has chosen to report through claims and using the Rheumatoid Arthritis Measure Group reporting options. (See the “Practice Page” for details on PQRI reporting types.)
How should this encounter be coded?