Code the following reports utilizing CPT codes, apply any application modifiers.
3. Description: The patient is a 26-year-old
female, referred to Physical Therapy for low back pain. The patient
has a history of traumatic injury to low back.
HISTORY OF PRESENT ILLNESS: The patient is a
26-year-old female, referred to Physical Therapy for low back pain.
The patient has a history of traumatic injury to low back. The
patient stated initial injury occurred eight years ago, when she
fell at a ABC Store. The patient stated she received physical
therapy, one to two visits and received modality treatment only,
specifically electrical stimulation and heat pack per patient
recollection. The patient stated that she has had continuous
low-back pain at varying degrees for the past eight years since
that fall. The patient gave birth in August 2008 and since the
childbirth, has experienced low back pain. The patient also states
that she fell four to five days ago, while mopping her floor. The
patient stated that she landed on her tailbone and symptoms have
increased since that fall. The patient stated that her initial
physician examination with Dr. X was on 01/10/09, and has a
followup appointment on 02/10/09.
PAST MEDICAL HISTORY: The patient denies high
blood pressure, diabetes, heart disease, lung disease, thyroid,
kidney, or bladder dysfunctions. The patient stated that she quit
smoking prior to her past childbirth and is currently not pregnant.
The patient has had a C-section and also an appendectomy. The
patient was involved in a motor vehicle accident four to five years
ago and at that time, the patient did not require any physical
therapy nor did she report any complaints of increased back pain
following that accident.
MEDICATIONS: Patient currently states she is
taking:
1. Vicodin 500 mg two times a day.
2. Risperdal.
3. Zoloft.
4. Stool softeners.
5. Prenatal pills.
DIAGNOSTIC IMAGERY: The patient states she has not
had an MRI performed on her lumbar spine. The patient also states
that Dr. X took x-rays two weeks ago, and no fractures were found
at that time. Per physician note, dated 12/10/08, Dr. X dictated
that the x-ray showed an anterior grade 1 spondylolisthesis of L5
over S1, and requested Physical Therapy to evaluate and
treat.
SUBJECTIVE: The patient states that pain is
constant in nature with a baseline of 6-7/10 with pain increasing
to 10/10 during the night or in cold weather. The patient states
that pain is dramatically less, when the weather is warmer. The
patient also states that pain worsens as the day progresses, in
that she also hard time getting out of bed in the morning. The
patient states that she does not sleep at night well and sleeps
less than one hour at a time.
Aggravating factors include, sitting for periods greater than 20
minutes or lying supine on her back. Easing factors include side
lying position in she attempts to sleep.
OBJECTIVE: AGE: 26 years old. HEIGHT: 5 feet 2
inches. WEIGHT: The patient is an obese 26-year-old female.
ACTIVE RANGE OF MOTION: Lumbar spine, flexion,
lateral flexion and rotation all within functional limits without
complaints of pain or soreness while performing them during
evaluation.
PALPATION: The patient complained of bilateral SI
joint point tenderness. The patient also complained of left greater
trochanter hip point tenderness. The patient also complained of
bilateral paraspinal tenderness on cervical spine to lumbar
spine.
STRENGTH:
RIGHT LOWER EXTREMITY:
Knee extension 5/5, hip flexion 5/5, knee flexion 4/5, internal and
external hip rotation was 4/5. With manual muscle testing of knee
flexion, hip, internal and external rotation, the patient reports
an increase in right SI joint pain to 8/10.
LEFT LOWER EXTREMITY:
Hip flexion 5/5, knee extension 5/5, knee flexion 4/5, hip internal
and external rotation 4/5, with slight increase in pain level with
manual muscle testing and resistance. It must be noted that PT did
not apply as much resistance during manual muscle testing,
secondary to the 8/10 pain elicited during the right lower
extremity.
NEUROLOGICAL: The patient subjectively complains
of numbness with tingling in her bilateral extremities when she
sits longer than 25 minutes. However, they subside when she stands.
The patient did complain of this numbness and tingling during the
evaluation and the patient was seated for a period of 20 minutes.
Upon standing, the patient stated that the numbness and tingling
subsides almost immediately. The patient stated that Dr. X told her
that he believes that during her past childbirth when the epidural
was being administered that there was a possibility that a sensory
nerve may have been also affected during the epidural less causing
the numbness and tingling in her bilateral lower extremities. The
patient does not demonstrate any sensation deficits with gentle
pressure to the lumbar spine and during manual muscle
testing.
GAIT: The patient ambulated out of the examination
room, while carrying her baby in a car seat.
ASSESSMENT: The patient is a 26-year-old
overweight female, referred to Physical Therapy for low back pain.
The patient presents with lower extremity weakness, which may be
contributing to her lumbosacral pain, in that she has poor lumbar
stabilization with dynamic ADLs, transfers, and gait activity when
fatigued. At this time, the patient may benefit from skilled
physical therapy to address her decreased strength and core
stability in order to improve her ADL, transfer, and mobility
skills.
PROGNOSIS: The patient's prognosis for physical
therapy is good for dictated goals.
SHORT-TERM GOALS TO BE ACHIEVED IN TWO
WEEKS:
1. The patient will be able to sit for greater than 25 minutes
without complaints of paraesthesia or pain in her bilateral lower
extremities or bilateral SI joints.
2. The patient will increase bilateral hip internal and external
rotation to 4/5 with SI joint pain less than or equal to
5/10.
3. The patient will report 25% improvement in her functional and
ADL activities.
4. Pain will be less than 4/10 while performing __________ while at
PT session.
LONG-TERM GOALS TO BE ACCOMPLISHED IN ONE
MONTH:
1. The patient will be independent with home exercise
program.
2. Bilateral hamstring, bilateral hip internal and external
rotation strength to be 4+/5 with SI joint pain less than or equal
to 2/10, while performing manual muscle test.
3. The patient will report 60% improvement or greater in functional
transfers in general ADL activity.
4. The patient will be able to sit greater than or equal to 45
minutes without complaint of lumbosacral pain.
5. The patient will be able to sleep greater than 2 hours without
pain.
TREATMENT PLAN:
1. Therapeutic exercises to increase lower extremity strength and
assist with lumbar sacral stability.
2. Modalities as indicated for pain and inflammation relief.
Modalities to include ice, heat, electrical stimulation and
ultrasound as appropriate.
3. Instruction of home exercise program/patient education.
FREQUENCY AND DURATION: The patient is to be seen
by Physical Therapy two times a week x4 weeks.
I have discussed the findings of the initial evaluation with the
patient. The patient is in agreement to the plan of care as
outlined above. We will refer the patient back to the physician if
the current plan does not seem to decrease the patient's pain level
or increase her functional abilities.
Thank you for this referral. If you have any questions, comments,
or concerns, please feel free to contact our office.
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Answer :
Physical therapy for low back pain.
CPT code is 97112 for all neuromuscular.
CPT codes : 72148, 72149, 72158.
For MRI and doing X - ray for lower back ache due to injury.
Modifier" M54.5"
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