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Coding Corner Question: Coding Scenario for 1997 Musculoskeletal Exam

  |  Issue: September 2018  |  

Assessment: The patient has possible general primary osteoarthritis. X-rays were ordered of shoulders and knees. Celecoxib 100 mg BID was recommended as needed and possible side effects, which are few, were discussed. I have also recommended ROM and quad strengthening exercises, which were demonstrated with patient participation and written information was given. Her neurologic exam is normal, but if her feeling of unsteadiness persists, she should see her primary care physician (PCP) for further evaluation. Her medical records are ordered from her PCP. She is scheduled to return to the office in four weeks.

How should this visit be coded using the 1997 musculoskeletal examination guidelines?

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