The Rheumatologist
COVID-19 News
  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed
  • Home
  • Conditions
    • Rheumatoid Arthritis
    • SLE (Lupus)
    • Crystal Arthritis
      • Gout Resource Center
    • Spondyloarthritis
    • Osteoarthritis
    • Soft Tissue Pain
    • Scleroderma
    • Vasculitis
    • Systemic Inflammatory Syndromes
    • Guidelines
  • Resource Centers
    • Ankylosing Spondylitis Resource Center
    • Gout Resource Center
    • Rheumatoid Arthritis Resource Center
    • Systemic Lupus Erythematosus Resource Center
  • Drug Updates
    • Biologics & Biosimilars
    • DMARDs & Immunosuppressives
    • Topical Drugs
    • Analgesics
    • Safety
    • Pharma Co. News
  • Professional Topics
    • Ethics
    • Legal
    • Legislation & Advocacy
    • Career Development
      • Certification
      • Education & Training
    • Awards
    • Profiles
    • President’s Perspective
    • Rheuminations
  • Practice Management
    • Billing/Coding
    • Quality Assurance/Improvement
    • Workforce
    • Facility
    • Patient Perspective
    • Electronic Health Records
    • Apps
    • Information Technology
    • From the College
    • Multimedia
      • Audio
      • Video
  • Resources
    • Issue Archives
    • ACR Convergence
      • Systemic Lupus Erythematosus Resource Center
      • Rheumatoid Arthritis Resource Center
      • Gout Resource Center
      • Abstracts
      • Meeting Reports
      • ACR Convergence Home
    • American College of Rheumatology
    • ACR ExamRheum
    • Research Reviews
    • ACR Journals
      • Arthritis & Rheumatology
      • Arthritis Care & Research
      • ACR Open Rheumatology
    • Rheumatology Image Library
    • Treatment Guidelines
    • Rheumatology Research Foundation
    • Events
  • About Us
    • Mission/Vision
    • Meet the Authors
    • Meet the Editors
    • Contribute to The Rheumatologist
    • Subscription
    • Contact
  • Advertise
  • Search
You are here: Home / Articles / Coding Corner Question: Coding Scenario for 1997 Musculoskeletal Exam

Coding Corner Question: Coding Scenario for 1997 Musculoskeletal Exam

September 19, 2018 • By From the College

  • Tweet
  • Email
Print-Friendly Version / Save PDF

A 55-year-old female patient with pain in multiple joints is referred to the office by her primary care physician. She complains of pain in both knees and both shoulders. She rates the pain at 7 on the pain scale. Her pain is worse at night after she gets off work. Soaking in her hot tub for about 45 minutes seems to reduce the pain to a 5 on a 10-point scale. She has taken acetaminophen, which does not help. She states she was unsteady on her feet a few times the previous week. She denies any weight gain or loss, dyspnea, dysuria, rashes or hair loss, dysphagia, stomach or abdominal symptoms, chest pain or mood changes. She has no known allergies. She has no other medical problems.

You Might Also Like
  • Coding Corner Answer: Coding Scenario for 1997 Musculoskeletal Exam
  • Rheumatology Coding Corner Question: Evaluation for Possible Systemic Lupus Erythematosus
  • Coding Corner Question: August
Explore This Issue
September 2018
Also By This Author
  • Rheumatology Coding Corner Questions: Eligibility Quiz

Past Medical History: The patient had a total hysterectomy five years ago for benign problems.

ad goes here:advert-1
ADVERTISEMENT
SCROLL TO CONTINUE

Family History: The patient’s mother had rheumatoid arthritis. She passed away last year in a car accident; this was not related to her rheumatoid arthritis. Her father passed away 10 years ago and had no rheumatic diseases. She has no siblings or children.

Social History: She does not smoke or consume alcohol.

ad goes here:advert-2
ADVERTISEMENT
SCROLL TO CONTINUE

Vital Signs: Her temperature is 98.7°F, height 5’6”, weight is 160 lbs., and blood pressure is 125/75 sitting. Patient is alert and oriented. She is well groomed.

The patient’s heart has a regular rate and rhythm, with no murmurs or rubs. Lymph nodes in her neck are not palpable to the touch. Skin has no scars or rashes on any extremities, face or trunk. Her coordination is good; she is able to touch her finger to her nose rapidly, and she is able to walk heel to toe. When the patient stretches her hands with palms turned inward over her head she has a small twinge on her right shoulder. Her deep tendon reflexes are normal in both lower extremities. When lightly touched by a pin with her eyes closed, she is able to identify the sensation of the pin on the upper and lower extremities. When asked, she correctly states the time, date and location. She is in a good mood even though she commented about pain.

Musculoskeletal Exam: Her gait and stance are normal. Her hands have Heberden’s nodes that are not tender, and proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints with full range of motion (ROM). There are no other bony deformities in upper or lower extremities. Her right shoulder has slight crepitus with passive motion but has full ROM and no pain and no palpable swelling. Other arm joints have no inflammation or tenderness. Her elbows have full ROM and no tenderness to palpation over joints or tendons. Her hips move well and are not tender. There is slight effusion and tenderness in both knees; her knees have full ROM. Her ankles and feet are normal. There is no joint laxity, and all joints are stable. Her neck and back are not tender and move well. Muscle strength and tone are good in both arms.

ad goes here:advert-3
ADVERTISEMENT
SCROLL TO CONTINUE

Pages: 1 2 | Single Page

Filed Under: Billing/Coding, From the College, Osteoarthritis Tagged With: Billing & Coding, MusculoskeletalIssue: September 2018

You Might Also Like:
  • Coding Corner Answer: Coding Scenario for 1997 Musculoskeletal Exam
  • Rheumatology Coding Corner Question: Evaluation for Possible Systemic Lupus Erythematosus
  • Coding Corner Question: August
  • Coding Corner Question

Rheumatology Research Foundation

The Foundation is the largest private funding source for rheumatology research and training in the U.S.

Learn more »

Simple Tasks

Learn more about the ACR’s public awareness campaign and how you can get involved. Help increase visibility of rheumatic diseases and decrease the number of people left untreated.

Visit the Simple Tasks site »

American College of Rheumatology

Visit the official website for the American College of Rheumatology.

Visit the ACR »

The Rheumatologist newsmagazine reports on issues and trends in the management and treatment of rheumatic diseases. The Rheumatologist reaches 11,500 rheumatologists, internists, orthopedic surgeons, nurse practitioners, physician assistants, nurses, and other healthcare professionals who practice, research, or teach in the field of rheumatology.

About Us / Contact Us / Advertise / Privacy Policy / Terms of Use

  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed

Copyright © 2006–2021 American College of Rheumatology. All rights reserved.

ISSN 1931-3268 (print)
ISSN 1931-3209 (online)

loading Cancel
Post was not sent - check your email addresses!
Email check failed, please try again
Sorry, your blog cannot share posts by email.
This site uses cookies: Find out more.