The Rheumatologist
  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed
  • Home
  • Conditions
    • Rheumatoid Arthritis
    • SLE (Lupus)
    • Crystal Arthritis
    • Spondyloarthritis
    • Osteoarthritis
    • Soft Tissue Pain
    • Scleroderma
    • Vasculitis
    • Systemic Inflammatory Syndromes
    • Guidelines
  • Drug Updates
    • Biologics & Biosimilars
    • DMARDs & Immunosuppressives
    • Topical Drugs
    • Analgesics
    • Safety
    • Pharma Co. News
  • Professional Topics
    • Ethics
    • Legal
    • Legislation & Advocacy
    • Career Development
      • Certification
      • Education & Training
    • Awards
    • Profiles
    • President’s Perspective
    • Rheuminations
  • Practice Management
    • Billing/Coding
    • Quality Assurance/Improvement
    • Workforce
    • Facility
    • Patient Perspective
  • Technology
    • Electronic Health Records
    • Apps
    • Information Technology
  • Resources
    • Issue Archives
    • Events
    • Multimedia
      • Audio
      • Video
    • From the College
    • American College of Rheumatology
    • Rheumatology Research Foundation
    • Arthritis & Rheumatology
    • Arthritis Care & Research
    • Treatment Guidelines
    • Research Reviews
    • Annual Meeting
      • Abstracts
      • Meeting Reports
    • Rheumatology Image Bank
    • ACR ExamRheum
  • About Us
    • Mission/Vision
    • Meet the Authors
    • Meet the Editors
    • Contribute to The Rheumatologist
    • Subscription
    • Contact
  • Advertise
  • Search
You are here: Home / Articles / Rheumatology Coding Corner Question: Evaluation for Possible Systemic Lupus Erythematosus

Rheumatology Coding Corner Question: Evaluation for Possible Systemic Lupus Erythematosus

November 9, 2017 • By From the College

  • Tweet
  • Email
Print-Friendly Version / Save PDF

History

You Might Also Like
  • Rheumatology Coding Corner Answer: Evaluation for Possible Systemic Lupus Erythematosus
  • Rheumatology Coding Corner Question: Level 4 New Patient Visit
  • Rheumatology Coding Corner Question: Established Patient Office Visit with Acute Gout
Explore This Issue
November 2017
Also By This Author
  • Letters to the Editor: In Memoriam

A 25-year-old female patient is seen in the office after her primary care physician requested a consultation for a possible diagnosis of systemic lupus erythematosus (SLE). The patient presents today with muscle pain in both legs, she rates the pain at an 8 on a scale of 10. She states she experiences throbbing, usually at the end of the day, which lasts for one to two hours. She complains of hair loss and experiences constant fatigue, even when she gets the proper amount of sleep. She has developed a rash on her cheeks and her right arm, and the rash worsens with exposure to the sun. The patient reports that the symptoms began approximately six months before. She takes ibuprofen to ease muscle pain. She denies joint pain or swelling, eye problems, chest pain, respiratory symptoms or gastrointestinal or genitourinary problems. She has not had an infection and has not traveled recently. She denies smoking and drinking alcohol. Family history is negative for systemic inflammatory diseases. Her mother has hypertension, and her father has diabetes.

ad goes here:advert-1
ADVERTISEMENT
SCROLL TO CONTINUE

Past History

She had chicken pox and measles as a child. She works full time as a dock worker.

ad goes here:advert-2
ADVERTISEMENT
SCROLL TO CONTINUE

Examination

The patient is alert. Her height is 5’5”, weight is 130 lbs., and her blood pressure is 115/80. Her heart rate is fast and regular at 125 beats/minute. Her respiratory rate is eight to nine breaths per minute. Her hair is thin. She has a malar rash, and the rash on her right arm has patchy redness. Her mouth has sores on the inside of her cheeks. Her lungs are clear; her heart has no murmurs, gallops or rubs. Her chest is not tender to palpation. Her abdomen is soft, nontender, with no masses or HSM. Her gait is stiff. Neurologic exam shows normal sensory exam and reflexes. All joints are normal. There is bilateral warmth, swelling and tenderness in her thigh muscles. She is also tender over her left tibia.

Assessment & Plan

ad goes here:advert-3
ADVERTISEMENT
SCROLL TO CONTINUE

Orders were written for an electrocardiogram, CBC, ANA, antiDNA, CK, urinalysis, TSH, serum creatinine, chemistries and LFTs.

The patient was prescribed 500 mg of chlorzoxazone up to three times a day for the muscle pain. She was counseled not to drive or consume alcohol when taking this medication and that she may wish to take it only when she returned home from work at the end of the day. She was scheduled to return to the office in two weeks.

Pages: 1 2 | Single Page

Filed Under: Billing/Coding, From the College, Practice Management Tagged With: Billing, Coding, office visit, patient care, Practice Management, rheumatologyIssue: November 2017

You Might Also Like:
  • Rheumatology Coding Corner Answer: Evaluation for Possible Systemic Lupus Erythematosus
  • Rheumatology Coding Corner Question: Level 4 New Patient Visit
  • Rheumatology Coding Corner Question: Established Patient Office Visit with Acute Gout
  • Rheumatology Coding Corner Question: Physical Examination with Infliximab Infusion

American College of Rheumatology

Visit the official website for the American College of Rheumatology.

Visit the ACR »

ACR/ARP Annual Meeting

Don’t miss rheumatology’s premier scientific meeting for anyone involved in research or the delivery of rheumatologic care or services.

Visit the ACR Annual Meeting site »

ACR/ARP Meeting Abstracts

Browse and search abstracts from the ACR/ARP Annual Meetings going back to 2012.

Visit the ACR/ARP Meeting Abstracts site »

The Rheumatologist newsmagazine reports on issues and trends in the management and treatment of rheumatic diseases. The Rheumatologist reaches 11,500 rheumatologists, internists, orthopedic surgeons, nurse practitioners, physician assistants, nurses, and other healthcare professionals who practice, research, or teach in the field of rheumatology.

About Us / Contact Us / Advertise / Privacy Policy / Terms of Use

  • Connect with us:
  • Facebook
  • Twitter
  • LinkedIn
  • YouTube
  • Feed

Copyright © 2006–2019 American College of Rheumatology. All rights reserved.

ISSN 1931-3268 (print)
ISSN 1931-3209 (online)

loading Cancel
Post was not sent - check your email addresses!
Email check failed, please try again
Sorry, your blog cannot share posts by email.
This site uses cookies: Find out more.