ICD-10 Academic Testing Physical and Occupational Therapy DESTINATION

Transcription

1 ICD-10 Academic Testing Physical and Occupational Therapy DESTINATION Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association

2 PT/OT Scenario #1 Narrative Title: PIL 3 Narrative Desc: Pain in limb Age: 54 Height: 69 BP: 130/70 Resp-rate: 16 Gender: Male Weight: 170 Pulse: 70 Temp: 98.6 Chief Complaint: Established patient being seen for evaluation of pain in right arm. Past Med. History: Patient is known to me. Is a non-smoker, non diabetic, but has had pain intermittently in his right arm for which he has been receiving PT. Office Visit Notes: During this visit we discussed his progress with the physical therapy exercises, including range of motion as well as strength training. He said the pain in the arm occurs less frequently and he feels he is benefiting from the therapy. Will evaluate in 2 weeks after 4 additional sessions. Drugs: None M79.6 M79.601D M M M M79609 M79.621

3 PT/OT Scenario #2 Narrative Title: AHM-1 Narrative Desc: Abnormal Head Movements Age: 39 Height: 62 BP: 132/72 Resp-rate: 16 Gender: Female Weight: 155 Pulse: 70 Temp: 98.7 Chief Complaint: Patient complains of abnormal head movements. Past Med. History: Patient has negative history other than abnormal head movements, cause unknown. She is a non-smoker and current on all immunizations. Office Visit Notes: This patient is known to me. She has abnormal head movements that consist of myoclonic jerks that involve frequencies of approximately 2 and 4 Hz. and hypotonia of the neck muscles. She has been evaluated by an ophthalmologist and has no discernible vision problems. Patient. states that her neck gets sore from the constant head movements so a series of massage and slow stretching exercises were completed as well as ultrasonography. Patient. was given a series of exercises to do at home also. Patient. has no questions at this time and will follow-up if there is not improvement with doing the home exercises.. Drugs: None The following ICD-9 Code(s) were chosen: The following ICD-10 Code(s) were chosen: R25 R25.0 M54.2 G R25.1 R251 R250 R259 R25.0XXD G25.3XXD M54.2XXS

4 PT/OT Scenario #3 Narrative Title: LMB-2 Narrative Desc: Lumbago Age: 65 Height: 70 BP: N/A Resp-rate: N/A Gender: Male Weight: 200 Pulse: N/A Temp: N/A Chief Complaint: Patient complains of low back pain. Past Med. History: Patient has a history of HTN and takes Lisinopril 30 mg. daily. He also takes Crestor 10 mg. daily and Ibuprofen 600 mg. every 6 hours as needed for back pain. Office Visit Notes: Patient referred by PCP for complaints of back pain. Patient states that he lifted something heavy 2 weeks ago and felt a pulling sensation and his lower back. Testing was done by his PCP and no abnormalities were found so PT was ordered. A series of stretching exercises were followed by manual traction to each side of the lower back followed by application of electrical stimulation to 4 areas of the back. Discussed proper body mechanics when lifting heavy objects and Patient also given exercises to improve strength for Patient. to do at home. Patient tolerated procedures well and understands the PT plan. Will return in 2 days for next appt. Drugs: Lisinopril, Crestor, Ibuprofen M54.5 W24.0XXA I10 M54.5XXD M545

5 PT/OT Scenario #4 Narrative Title: MSW-2 Narrative Desc: Muscle Weakness (generalized) Age: 51 Height: 70 BP: N/A Resp-rate: N/A Gender: Male Weight: 185 Pulse: N/A Temp: N/A Chief Complaint: Patient with complaints of generalized muscle weakness Past Med. History: Patient has no known medical history. Office Visit Notes: Patient was referred by his PCP for generalized muscle weakness. Patient is a contractor who was working overseas for several months. Upon his return, he saw his PCP and multiple tests were run. No known etiology was found for complaints, so PT was ordered to assess and treat symptoms. Patient shown and able to demonstrate stretching and joint mobilization exercises. Other exercises shown to patient are postural, stabilization, coordination, proprioception, balance and agility as well as strengthening. Patient encouraged to stretch all tight muscles and to perform exercises at home. Patient tolerated all treatment and an assessment showed patient to have generalized weakness of all 4 extremities equally. Patient states that he is able to do all ADLs, but tires easily due to the muscle weakness. Patient denies any pain. Will see patient in two days to continue outpatient treatment plan. Drugs: None R53.1 M62.81 M6281

6 PT/OT Scenario #5 Narrative Title: MAM-2 Narrative Desc: Myalgia and Myositis, unspecified (Fibromyalgia) Age: 35 Height: 68 BP: N/A Resp-rate: N/A Gender: Male Weight: 155 Pulse: N/A Temp: N/A Chief Complaint: Patient complains of pain related to fibromyalgia Past Med. History: Patient has history of fibromyalgia at takes Lyrica 450 mg. daily. Office Visit Notes: Patient referred by PCP for PT Eval and treatment for fibromyalgia pain. Patient complains of pain mostly in the neck and shoulder region and the upper back. Observed muscles in these areas to be very taught. Patient explained that his symptoms are exacerbated by stress and that he has been under a great deal lately. Discussed with patient, methods to reduce stress including deep breathing techniques and to try to avoid stressful situations when possible. Patient also shown several exercises to develop strength and to increase range of motion and flexibility. Manual traction was applied to both sides of the neck, shoulders and upper back and massage was also performed. Patient tolerated procedures and exercises well with minimal discomfort. Patient had limited ROM in the neck area which he states is the most painful. Patient encouraged to do exercises at home and copies of instructions for them were given to patient. Patient will follow-up in two days for the next treatment. Drugs: Lyrica M79.1 M60.89 M79.1 M54.2 M79.7 M M60.88 M M609 M791 M797

7 PT/OT Scenario #6 Narrative Title: Cev-1 Narrative Desc: Cervicalgia Age: 41 Height: 65 BP: N/A Resp-rate: N/A Gender: Female Weight: 150 Pulse: N/A Temp: N/A Chief Complaint: Patient complains of neck pain Past Med. History: Patient has a negative medical history. Patient takes Ibuprofen 800 mg. every 6 hours as needed for neck pain Office Visit Notes: Patient is known to me and is being seen for complaints of neck pain. She denies any known injury and states that she woke up one morning and her neck was very painful. She states that it hurts worse when she turns her head and she thinks that maybe she slept on it wrong. She has had symptoms for 1 week and has had no relief of symptoms. A hot pack was applied to help relax the neck muscles prior to massage being done on either side of the neck area. Patient was also given exercises to do at home to help strengthening and increase ROM. Patient states that she has been compliant with the exercises and that she is able to turn her head more easily with less discomfort than she had experienced prior to therapy. Patient tolerated procedures well and will return in 2 days for next appt. Patient also counseled on proper lifting techniques and discouraged from carrying a heavy shoulder bag. Explained that if she needs to carry a heavy purse, that she would be better off using a backpack type that would evenly distribute the weight. Drugs: Ibuprofen M54.2 M62.838

8 PT/OT Scenario #7 Narrative Title: MAM-1 Narrative Desc: Myalgia and Myositis, unspecified Age: 53 Height: 68 BP: N/A Resp-rate: N/A Gender: Male Weight: 155 Pulse: N/A Temp: N/A Chief Complaint: Patient complains of pain related to fibromyalgia, sprain of ribs, initial encounter Past Med. History: Patient has history of fibromyalgia and takes Lyrica 450 mg. daily. Office Visit Notes: Patient is known to me and is under treatment for fibromyalgia pain. Patient also recently sprained his rib while playing baseball. Patient complains of pain in the neck and shoulders and the right rib area, especially with deep breathing and/or coughing. Observed muscles in the neck and shoulder areas to be very taught. Patient explained that his fibromyalgia symptoms are exacerbated by stress and that he has been under a great deal lately. Discussed with patient, methods to reduce stress including deep breathing techniques (which would also help with his rib injury) and to try to avoid stressful situations when possible. With patient lying on the exam table, OMT was performed on the neck and upper shoulders areas. Patient tolerated procedures and exercises well with minimal discomfort. Patient has limited ROM in the neck area which he states is the most painful. Patient encouraged to do exercises at home and copies of instructions for them were given to patient. Patient will follow-up in two days for the next treatment. Drugs: Lyrica T14.8 M60.9 Y93.64 M M54.2 M79.1 M79.7 M791 R07.82 M609 S23.41XA M25.519

9 PT/OT Scenario #8 Narrative Title: CTS-1 Narrative Desc: Carpal Tunnel Syndrome Age: 55 Height: 67 BP: N/A Resp-rate: N/A Gender: Female Weight: 180 Pulse: N/A Temp: N/A Chief Complaint: Established patient being seen for carpal tunnel syndrome of left upper limb Past Med. History: Patient is not on any medications other than Motrin 600 mg. as needed for left arm discomfort. Office Visit Notes: This Patient is known to me, she has been receiving treatment for carpal tunnel syndrome of the left upper limb. Patient performed exercises to increase ROM and flexibility with less discomfort than the prior visits. She states that she is doing her exercises at home and it seems to be helping. Deep tissue manipulation was done to multiple areas of the upper arm after patient performed her exercises. Patient states that her muscles feel less tight since starting therapy and that she has felt an overall improvement. Patient will return in three days for her next visit. Drugs: Motrin G56.0 G56.02 M G5600 M25.522

10 PT/OT Scenario #9 Narrative Title: ABG-1 Narrative Desc: Abnormality of Gait (Unsteadiness on feet) Age: 53 Height: 65 BP: N/A Resp-rate: N/A Gender: Female Weight: 160 Pulse: N/A Temp: N/A Chief Complaint: Patient here for PT appt. due to abnormality of gait Past Med. History: Patient has history of HTN and takes Lisinopril 40 mg. daily and also takes pantoprazole NA 40 mg. daily for GERD. Office Visit Notes: This Patient is known to me and is here for her scheduled PT appt. for gait abnormality. Patient was able to perform exercises for strengthening and endurance. Both active and passive exercises were performed and neuromuscular reeducation and proprioception for sitting and standing activities were also done. Encouraged patient to continue exercises at home and walking was recommended. Discussed safety measures to do, such as having someone accompanying her while walking and to avoid doing activities alone, especially when feeling unsteady. Patient observed and there doesn't appear to any safety concerns as long as she uses her 3 prong cane or walker. Patient will return in three for her next appt. Drugs: Lisinopril, Pantoprazole R26 R26.9 R26.89 R26.87 R26.81 I10 R21.9 R269 R260 R261 R2689

11 PT/OT Scenario #10 Narrative Title: OCD-1 Narrative Desc: Osteochondritis Dissecans (Osteochondritis dissecans, right knee) Age: 16 Height: 64 BP: N/A Resp-rate: N/A Gender: Female Weight: 115 Pulse: N/A Temp: N/A Chief Complaint: Patient complains of pain and swelling of the right knee. Past Med. History: Patient has negative medical history and is current with all immunizations. Patient takes Ibuprofen 600 mg. every 6 hours as needed for pain and swelling of the knee. Office Visit Notes: Patient was referred from PCP for Osteochondritis dissecans of the right knee. Patient had MRI completed that confirmed diagnosis. PT assessment showed a positive Wilson's test. Patient states that she experiences popping and clicking of the knee at times which is painful. Patient was shown ROM exercises, stretching, and strengthening/stabilization exercises. Patient was able to demonstrate proper technique with some discomfort. Patient was given printed instructions of the exercises and was encouraged to do them at home also. Patient will return in a few days for her next appt. Drugs: Ibuprofen M93.25 M M M M M M M9320 M93.262

12 PT/OT Scenario #11 Narrative Title: TFI-1 Narrative Desc: T7-12 open fx w/unspecified spinal cord injury (Unspecified fracture of T7-T8 vertebra, initial encounter for open fracture and Unspecified injury at T7-T10 level of thoracic spinal cord, initial encounter) Age: 50 Height: 64 BP: 130/78 Resp-rate: 18 Gender: Female Weight: 155 Pulse: 76 Temp: 98.6 Chief Complaint: Patient complains of back pain related to recent surgery Past Med. History: Patient is taking Lortab 7.5 mg., one to two tabs every 4-6 hours as needed for severe pain and/or Motrin 800 mg. every 6 hours as needed for pain. Office Visit Notes: This is a new patient that was referred to me after being hospitalized from an open fracture of T7-T8 vertebra with injury to the spinal cord. Patient was a passenger on her husband's motorcycle when they were hit by a truck and he is still in Intensive Care for critical injuries. Patient had surgery to repair the injury and she is also suffering from a spinal concussion. Patient is accompanied by her daughter today. Patient has steri strips to her back that are clean, dry and intact and without drainage. Vital signs are stable, lungs are clear and Patient states that pain is well controlled with her prescribed medications. Patient suffered a spinal cord concussion at the T7-10 level and had resulting motor weakness of the upper extremities that resolved a couple of days following surgery. Discussed plan to have Patient go through PT/OT evaluation and treatment to increase ROM and strengthening. Patient has some residual weakness of the upper extremities, but is able to perform her ADL's and care for herself. Her daughter is temporarily staying with Patient for a few weeks to drive her to her appointments and take her to visit her husband in the hospital. Patient to start therapy tomorrow and neither Patient nor daughter have any questions at this time. Drugs: Lortab, Motrin S S22.069A S24.153A M S22.069B Z S24.0XXA R V S24.103A S22.068B M62.81 S24103A S S22.068S S24104A

13 PT/OT Scenario #12 Narrative Title: SSS-1 Narrative Desc: Sprains and strains of sacroiliac region (Sprain of unspecified parts of lumbar spine and pelvis, initial encounter) Age: 66 Height: 65 BP: 138/76 Resp-rate: 18 Gender: Female Weight: 165 Pulse: 76 Temp: 98.6 Chief Complaint: Patient complains of lower back pain. Past Med. History: Patient has history of HTN and takes Lisinopril 20 mg. daily. Patient is taking Lortab 7.5 mg., one to two tabs every 4-6 hours as needed for severe pain and/or Motrin 800 mg. every 6 hours as needed for pain. She is also taking Valium 5 mg. as needed for back spasms. Office Visit Notes: This patient is known to me. She is under treatment for a sprain of the lumbar spine and pelvis. MRI confirmed that there were no gross abnormalities. Patient was lifting bags of mulch when she experienced a sudden stabbing pain that "brought her to her knees". She was unable to straighten up and her husband took her to the ER for evaluation. Tests, including MRI were done and confirmed above mentioned diagnosis. Patient states that she is still experiencing back pain and spasms, but the exercises that she has been doing at her PT appointments and at home have been helping. She states that her pain is mostly controlled with Motrin, but she has to take Lortab and Valium on occasion for muscle spasms and severe pain. Upon examination, Patient still has decreased ROM and flexibility of her lower back, but it has improved since last visit. Plan is to continue with PT and Patient to follow-up in the office in 2 weeks. Patient has no questions at this time. Drugs: Lisinopril, Lortab, Motrin, Valium S33.9 S33.9XXA M M M53.2 S33.6XXA S33.6XXD S33.8XX S33.5XX S33.8XXA S339XXA S73.109A M99.04 I10

14 PT/OT Scenario #13 Narrative Title: PJH-2 Narrative Desc: Pain in Joint, hand (right hand) Age: 63 Height: 65 BP: N/A Resp-rate: N/A Gender: Female Weight: 150 Pulse: N/A Temp: N/A Chief Complaint: Patient complains of pain in the right hand. Past Med. History: No significant medical history. Current medications - Cardizem 25 mg. twice daily for HTN and Crestor 10 mg. for high cholesterol and Motrin 800 mg every 6 hours as needed for right hand pain. Office Visit Notes: Patient is here for therapy to her right hand due to pain in joint. Patient denies any known injury. Her PCP ruled out arthritis and carpal tunnel syndrome. Patient completed her assigned exercises for strengthening and to increase ROM and manual manipulation and traction was performed on several areas of the hand. Worked with patient on dynamic activities to improve functional performance. Paraffin bath and ultrasound applied 15 minutes each to the right hand. Patient tolerated therapy well with minor discomfort. She states that she has been doing her exercises at home and has noticed that there has been a decrease in pain. Patient scheduled to return in 3 days. Drugs: Cardizem, Crestor, Motrin M25.50 M M79.64 M79.643

15 PT/OT Scenario #14 Narrative Title: LOC-1 Narrative Desc: Lack of coordination Age: 7 Height: N/A BP: N/A Resp-rate: N/A Gender: Male Weight: N/A Pulse: N/A Temp: N/A Chief Complaint: Lack of coordination has problems with balance and fine-motor skills. Parent s state that son is behind other children his age in motor skills and classroom performance. Past Med. History: Current on immunizations. No family history of ataxia. No current medications Office Visit Notes: Patient here for treatment of issues related to lack of coordination. Patient has been responding well to therapy. Today's focus is on transitional movements and self care activities. We worked on crawling, prone on elbows and skipping. Initially, patient had poor proximal stabilization, he has made progress towards goal of being able to crawl with good reciprocal movements. He still exhibits difficulty in holding head up during prone activity, he is only able to hold that position for less than a minute we continue to work towards a goal of 2 minutes. His skipping skills lack fluency. Encouraged parents to work on these skills at home. With self care activities, patient continues to have difficulties with clothing fasteners as a result of his decreased coordination and strength in his hands. He is able to dress independently but still needs moderate assistance with buttoning of his shirt and fastening his pants. Patient to practice these skills at home and return to clinic in 2 days. Drugs: None R27.8 F82 R27.9 R279 R278 R62.50 R26.81 R81.9

16 PT/OT Scenario #15 Narrative Title: AUD-1 Narrative Desc: Autistic Disorder Age: 14 Height: N/A BP: N/A Resp-rate: N/A Gender: Male Weight: N/A Pulse: N/A Temp: N/A Chief Complaint: Impairment of social skills, difficulty with communication. Past Med. History: Doctor with Autism Spectrum Disorder at the age of 2. Office Visit Notes: Patient undergoing therapy to improve behaviors associated with autistic disorder. Patient has been making progress on the majority of our established goals. Today we focused on sensory integration. Started with massage and deep touching. The weighted vest was applied. Worked on desensitization using the brushing program; systematically brushing his body at regular intervals throughout the session. Patient did well in today's session. Mother instructed on activities to have patient work on at home. Patient to return in one week. Drugs: None V62.4 F84.0 R Z73.4

17 PT/OT Scenario #16 Narrative Title: HDS-1 Narrative Desc: Hemiplegia affecting dominant side Age: 18 Height: N/A BP: N/A Resp-rate: N/A Gender: Male Weight: N/A Pulse: N/A Temp: N/A Chief Complaint: Patient has right sided weakness affecting his range of motion (ROM), movement and function on dominant side. Past Med. History: 3 months post Motor Vehicle Accident (MVA) Office Visit Notes: Patient undergoing treatment of hemiplegia and hemiparesis affecting dominant side following motor vehicle accident (MVA). Patient has been making progress on the majority of our established goals. Today we focused on grooming goals. We worked on washing hands and feet and cutting toe and finger nails. Patient expressed frustration after dropping the nail clippers multiple times when cutting the nails on his left side. He's able to dress independently, but needs help with the fine motor skills of buttoning his shirts and pants. He uses his left hand to close the zipper on his pants. Patient did well with combing his hair and joked that it was easy since he didn't have that much hair to begin with. Patient encouraged to practice the skills we worked on today. Next appointment, 3 days. Drugs: None G81.91 I G81.9 G V89.9XXD I

18 PT/OT Scenario #17 Narrative Title: MWD-1 Narrative Desc: Muscular Wasting and Disuse Atrophy, NEC Age: 25 Height: N/A BP: N/A Resp-rate: N/A Gender: Male Weight: N/A Pulse: N/A Temp: N/A Chief Complaint: Limited range of motion to right shoulder, no strength in arm and is unable to lift arm without support from left arm. Past Med. History: Injured his right shoulder playing softball 3 months ago. Office Visit Notes: Patient referred by his PCP for OT evaluation of muscular wasting and disuse atrophy of his right shoulder. Patient states that he fell while playing softball and since then has had limited movement and has tended to favor that arm by doing everything with his left arm. An activity analysis was performed to establish what movements; postures, strength and stamina are needed in order to develop a treatment plan to return pt to pre-injury condition. Reviewed plan with patient and he agreed. Patient started out with neuromuscular re-education and range of motion exercises. (see plan of care for specific activities). Patient tolerated well, stated he was having some discomfort during the range of motion (ROM) activities. Patient to return to office in 2 days to continue with treatment plan. Drugs: None E007.3 M62.51 M M Y M62.50 M W01.0XXD M6250 Y93.69 M25.522

19 PT/OT Scenario #18 Narrative Title: SSW-1 Narrative Desc: Sprains and Strains of Wrist and Hand Age: 24 Height: N/A BP: N/A Resp-rate: N/A Gender: Female Weight: N/A Pulse: N/A Temp: N/A Chief Complaint: Weakness in right wrist and hand Past Med. History: History of repetitive trauma injury Office Visit Notes: New patient. Patient here for therapeutic exercises to right wrist/hand due to strain/sprain. Initial evaluation conducted and developed a plan of care. Created goals to gain motion and improve mobility and reduce pain. Patient agrees with plan. Patient wears a removable splint to her right wrist when awake. Started therapy plan that consisted of manual joint mobilization, stretching and strengthening of muscle. Demonstrated exercises that patient is to work on at home that will promote self management. Patient states she has noticed improvement in range of motion and reduction of pain. Patient to return in 1 week. Drugs: None M S S63.8X1A S66.911A M62.81 S63.501A S63.9 S66.919A M S63.521A S63.90XA S66919A S63.50

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