A 68-year-old female Medicare patient with a diagnosis of primary osteoarthritis of the left knee returns to a practice for her third injection in a series of knee injections. She reports being able to resume her after-dinner walks, which last for 30–40 minutes at least twice weekly. She denies fevers or any rashes. She has tried multiple weight loss programs, but is having little success because her appetite is unchanged. She denies vomiting, diarrhea, hematochezia, chest pain, dyspnea or other complaints. Ibuprofen (800 mg), acetaminophen and other non-steroidal anti-inflammatory drugs (NSAIDs) have failed to relieve the pain in her knee. The patient’s weight is 220 lbs., height is 5’2″ and BMI is 40.2.
The left knee was injected with 2 mL of hyaluronic acid (Synvisc) under aseptic technique without complications. Due to her weight and her fixed left knee flexion of 13º, the injection was performed with ultrasound guidance. A permanent picture of the injection point was added to the patient’s medical chart.
She was sent home with instructions to rest for 48 hours, to use an ice pack for any swelling and to call if the knee became extremely painful or if she had any systemic symptoms, such as fever.
Diagnoses:
- Primary osteoarthritis of left knee
- Morbid obesity
How should this be coded?
Editor’s note: Case vignettes presented in the Coding Corner are created to illustrate questions about coding. They are not intended to represent the full medical record of a case.