A new 70-year-old female patient who has Medicare is scheduled for a visit with the rheumatologist. She was referred to this specialist by her primary-care physician for postmenopausal osteoporosis. The rheumatologist performs a comprehensive history, comprehensive examination, and engages in medical decision making of moderate complexity.
After a treatment course is decided, the physician concludes that a dual-energy X-ray absorptiometry (DXA) scan is needed. The patient had a previous bone-mass measurement procedure that was ordered by her primary-care physician two years ago. The patient reports that, one year ago, she had a fall that resulted in a pathological fracture of the left hip that has completely healed. The physician sends her to the imaging room for a DXA of the axial skeleton and a vertebral fracture assessment, and schedules her for a follow-up visit in a month.
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