Exam: The patient’s weight is 200 lbs., her height is 5 feet, and her temperature is 98.7ºF. The HEENT exams show pupils that are round with clear sclerae, no mouth ulcers and no hearing loss. Her heart rate is within normal limits, and her heart sounds are normal. Her abdomen is not distended or tender. Her lungs are clear to auscultation. Except for the left knee, the musculoskeletal exam is normal. Her left knee is swollen, warm and tender to the touch. She has pain in the left knee. Her knee lacks 5 degrees of full extension and has a range of motion of only 45 degrees. Her gait is unstable with a tilt to the left side when she is walking across the room.
Assessment & Plan: The patient is in a lot of pain and wants to proceed with her scheduled knee joint injection. After obtaining a prior authorization, the patient is given her injection of Synvisc One, her second for the year. The patient is obese, so the injection is done via ultrasound guidance, and a permanent recording of the guidance is entered in the patient’s medical record.
Which scenario should be coded as follows?
CPT: 99214-25, 20611-LT, J1030
ICD-10: M05.79, M25.562
