A 32-year-old male patient with rheumatoid arthritis affecting multiple joints without rheumatoid factor returns to the office for a follow-up visit with the nurse practitioner (NP). The patient states his overall pain has improved since his previous visit, although he rates the severity of his right shoulder and right wrist pain at a 5 on a 10-point scale. He is currently on 15 mg methotrexate by mouth weekly. He reports no chest pain, dyspnea or gastrointestinal symptoms. He has no known medical allergies.
Past medical history: Appendix removed the previous year.
Family history: His mother and father are currently living and have no history of rheumatoid arthritis.
The patient’s weight is 210 lbs., his height is 6′, and his temperature is 98.1°F. The patient is well groomed and alert. His heart has a regular rate and rhythm (RRR), and his lungs are clear. The abdomen is soft, flat and not tender. Bowel sounds are normal, and there are no bruits. His skin is warm and smooth. His joints have a normal range of motion and no synovitis or effusion. His right shoulder is slightly tender with motion, but has normal range of motion (ROM). Lab tests show his white blood count (WBC) is normal at 5.5 M/uL.
A diagnostic ultrasound is completed on the patient’s right shoulder.
The patient appears to be stable overall, with mild disease exacerbation in the shoulder. He is advised to continue his current dose of methotrexate and scheduled to return to see the NP in eight weeks.
Is the shoulder ultrasound a billable service? If so, what would it be?
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.
