Coding Corner Question: May

A 65-year-old female established patient with RA returns to the office for a follow-up visit. She still has pain, stiffness, and swelling in her left hand, elbow, and neck. The pain is considerably worse in the morning. She denies any fevers, cough, or dyspnea. The physician performs an expanded problem-focused exam.

A two-view X-ray of the left hand is performed and results are read during the visit. The hand X-ray is negative. Because of the severity of the neck and upper back pain, five trigger-point injections are given, including the right and left trapezius, right and left rhomboid, and right paraspinal muscles. No medication is changed.

What is the correct way to bill this visit?

A 27-year-old, left-handed man was referred to our ultrasound clinic for left elbow pain. History The patient had been a pitcher on a Minor League Baseball team. Two years before, he developed sudden, severe medial elbow pain while pitching in a game. The pain was associated with some tingling down the left medial forearm. The…

A 57-year-old Ghanaian woman was referred to our rheumatology practice with acute, left elbow swelling and pain. The referring oncologist suspected gout, because the patient had hyperuricemia. Six months before, the patient was diagnosed with stage IV human T-lymphotropic virus type 1 (HTLV-1)-associated adult T cell lymphoma (ATLL). Her initial oncologic manifestations included multiple thoracic,…

A 54-year-old African American man arrived at the emergency department with the acute onset of a tender mass on the left side of his neck. It had been getting progressively larger for the preceding two days. History & Examination His history included chronic right hip osteoarthritis with two surgeries performed five years prior. At his…

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