Question: A 51-year old female patient is seen for a follow-up visit for her seronegative rheumatoid arthritis that is affecting multiple sites. There is no organ or systems involvement. The physician performed a detailed history and examination, and the medical decision making was of moderate complexity.
During the encounter, the patient complained of swelling in the right knee with throbbing knee pain. She states her pain is a 9 on a 10-point scale and her pain has gotten gradually worse over the past five weeks. Ibuprofen has not relieved the pain. The musculoskeletal exam is normal except for the right knee, which is tender to the touch and swollen. Patient is taking sulfasalazine 500 mg tablets by mouth, 3 times a day. Along with the severe pain in the right knee, the knee lacks 5 degrees of full extension, and the range of motion is less than 45 degrees. Her gait is unstable, and she leans to the right side. Secondary osteoarthritis is suspected, and an x-ray is ordered to confirm the diagnosis.
Patient elects to have a knee joint injection for the pain, and 80 mg of methylprednisolone acetate is administered via ultrasound guidance due to the patient’s weight of 300 pounds. A permanent recording of the ultrasound guidance is entered in the patient’s record. The patient was also given a prescription for the pain and is to return in four weeks.
What CPT and ICD-10-CM codes should be reported?
Answer and rationale here.