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Original Question
Howard Bengal, MD 9878 Jefferson Road Mount Randall, NY 34883 Patient: Bolts, Belinda Date of Birth: 11/25/19xx Dear Dr. Bengal: Date of Service: 07/31/20xx Thank you for referring Ms. Belinda Bolts for evaluation today. As you know, she is a pleasant, 83-year-old Medicare patient who had a previous right total knee replacement and now complains of right shoulder pain for quite some time now. She states that her shoulder pain started approxi- mately 6 to 7 years ago after a fall on the ice, and since that time the pain has been progressive. She did have a full evaluation at that time, and there was no evidence of any fractures or dislocations. Her main complaint right now is both decrease in motion, especially with cross arm adduction, and also pain about the shoulder. She has had no other conservative measure- ment, including injections. She does state that she has pain in the shoulder almost constantly and has pain sleeping on that shoulder at night. She does find that she is starting to be limited by the pain and also experiencing loss of range of motion of that shoulder. Current Medications: Premarin, potassium, and Maxzide. Allergies: Sulfa. Past Medical History: High blood pressure and also arthritis. Past Surgical History: Right total knee replacement done on June 22, 2004, in addition to a hysterectomy. Family History: She has a history of diabetes on her mother’s side and also a family history of arthritis. Other Health Problems: She denies smoking. She states an alcohol history of approximately 1 to 2 drinks per week. She does not exercise regularly. She does not need assistance with daily activities and does not use any type of assistance device for walking. Review of Systems: Negative for fever, weight gain, chills. Negative for nausea and vomiting. No other musculoskeletal problems. Physical Examination: On physical examination today, she is 5 feet 2 inches tall. She weighs 165 pounds. There was no tenderness to palpation of her cer- vical spine, and she had painless range of motion of her cervical spine with a negative Spurling maneuver. There were no rashes, erythema, or ecchymosis about the right shoulder. She also had 2+ pulses distally in her radial artery. She did have mild tenderness to palpation over the acromioclavicular joint, mild tenderness to palpation over the biceps tendon and also laterally over the greater tuberosity. Her active forward flexion was to 150 degrees, external rotation with the arm at the side was to 45 degrees, and internal rotation was only to the sacrum. She had 4+/5 strength throughout her rotator cuff muscu- lature. She had full and painless range of motion of her right elbow. Imaging Studies: Three views of the right shoulder were obtained. AP, scapular Y, and axillary lateral view of the right shoulder show joint space narrowing of the glenohumeral joint with osteophyte formation off of the inferior aspect of the humerus. The humeral head appears to be well located on the glenoid and the axillary lateral view, with no significant posterior erosion of the glenoid. Impression: Right shoulder osteoarthritis. Plan: The nature and etiology of the diagnosis was explained to Ms. Bolts. We stated at this time that she does have arthritis of her shoulder. Whether this was hastened after her fall, we told her it was difficult to say. From her clinical examination today, she still has fairly decent range of motion except that she has lost a significant amount of internal rotation. The films show clear-cut evidence of joint space narrowing and osteophyte formation on the humeral head. Treatment plans would be conservative with a shoulder injection and also physical therapy for some strengthening exercises versus a total hemiarthroplasty replacement. At this time, she would like to proceed with some of the conservative measures first. She was given a cortisone injection of her shoulder through an anterior approach with which she had relief of 75% of her pain. She was given a prescription for physical therapy. We will see her back in the office in 6 weeks for a repeat clinical evaluation. Thank you again for allowing me to participate in Ms. Belinda Bolts’ care. If you have any further questions, please feel free to contact me at any time. Sincerely, Johnathan Bones, MD Compliance Medical Group PROCEDURE NOTE Diagnoses: 1. Right shoulder osteoarthritis. 2. Pain in joint. The risks and benefits of the shoulder injection with cortisone were dis- cussed with the patient. Under full informed consent, the anterior aspect of the right shoulder was prepped using a Betadine solution followed by an alcohol solution. Then 1 cm lateral and 1 cm proximal to the coracoid pro- cess the anterior glenohumeral joint was entered, and 6 cc of lidocaine and 2 cc of Depo-Medrol were injected without difficulty. There were no com- plications, and the patient tolerated the procedure well. Johnathan Bones, MD Compliance Medical Group Charge Ticket Patient Name Medical Record Number/Account Number Physician Practice Name Insurance Company Date of Birth Belinda Bolts 388776 Johnathan Bones, MD Compliance Medical Group Medicare Part B 11/25/19xx Date of Service Place of Service CPT Code Diagnosis Code(s) Modifier Quantity Fee 07/31/20xx 11 99203 M19.011 25 1 125.00 07/31/20xx 11 20610 M19.011 1 90.00 1) Choose a MDM Level (straightforward, low, moderate, or high) 2) Choose an E/M code as applicable. 3) List any other applicable billable services (CPT code(s)) 4) List any and all Diagnosis code(s) 5) Make a decision – Is the charge ticket accurate per your audit? Why? Why not?
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