On Nov. 4, a 55-year-old female patient presents to the office for a follow-up visit for injection of the left knee for osteoarthritis. This is her third of three injections that were preauthorized through Oct. 31. She reports pain and swelling in her left knee and rates the pain at an 8 on a 10-point scale. She states the pain is worse in the evening after she gets home from work. She works in the company mailroom and is on her feet four to six hours a day, Monday through Friday. The pain lasts for approximately two hours after soaking in a tub. She is currently taking 200 mg of celecoxib twice daily and 400 mcg of folic acid daily.
The patient denies fevers, headaches, chest pain, dyspnea, cough, oral ulcers, rashes, insomnia, gastrointestinal symptoms and depression. She has no known allergies.
Upon examination, the patient’s weight is 290 lbs., height is 5 feet 9 inches and temperature is 98.5º. HEENT: Her eyes were clear. She had no lesions or scars in the ears or nose. The heart rate and rhythm were within normal limits. Her lungs were clear. The left knee is tender and swollen to the touch and flexes to only 50 degrees.
The rheumatologist prepares the left knee for an injection of 3 mL of lidocaine. The rheumatologist also injects the left knee with 16 mg of Synvisc-One.
How should this be coded?
