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FU GENERALIZED PAIN TEST Chart #
DOB:
PRESENT ILLNESS INFORMATION
Chief Complaint:
S1: Patient presents for a pain management follow-up. Doing very well currently. Legs will still hurt in the evening so
she sits and rests. She picks up her grandkids from school every day. Rates her pain today
tolerable.She reports good relief with current treatment plan. Her activities have increased a lot since the last visit. No new problems or concerns. No new symptoms.
REVIEW OF SYSTEMS
Constitutional Symptoms: generalized aching.
Cardiovascular: leg cramps or pain in legs when walking a short distance; and swelling including ankles or legs.
Musculoskeletal: muscle tenderness; back pain; stiffness in joints; and weakness.
Endocrine: excessive fatigue; and feeling cold.
PAST, FAMILY AND SOCIAL HISTORY
Current
Medications:
DSS (100 MG)Gabapentin (400 MG)Hydrocodone-Acetaminophen (10-325 MG)KlonoPIN (1 MG)Levoxyl (100 MCG)MS Contin (100 MG)Neurontin (100 MG)Norco (10-325 MG)Pantoprazole Sodium (20 MG)Protonix (20 MG) Medication
Allergies:
Non-Medication
Non-Medication Allergies: no information provided.
Allergies:
Past Health History: Respiratory: asthma.
Musculoskeletal: osteoarthritis; fibromyalgia; and osteoporosis.
Neurologic: stroke (CVA).
Psychiatric: depression.
Endocrine: thyroid dysfunction.
Surgeries and
Previous surgeries: Other surgery: hysterectomy , lumbar laminectomy and fusion,
Hospitalizations:
Family History:
Cardiovascular: Heart disease in a female after age 55 - mother.
Neurologic: Stroke - father.
Social History:
Patient is retired.
Current tobacco usage: none.
Past (discontinued) use of tobacco products: none.
Current use of alcoholic beverages: Patient is a light drinker.
Recreational drug use: none.
Drug addiction or dependency: none.
Second-hand smoke exposure: none.
Hand dominance: left.
Home living situation and relationships: Lives with spouse.
OBJECTIVE
CONSTITUTION:
Blood Pressure: Right arm - Sitting 122/60 mm Hg. Radial Pulse: 87 bpm regular. Temperature: 99.7 F (oral).
Height: 62in. Weight: 190lbs. BMI: 34.8 kg/m2. Pulse Oximetry Reading: 93%.
General appearance: well developed. Obese; easily responsive to visual, verbal and tactile stimulation; oriented x 4;
cooperative.
Ability to communicate: normal.
EYES: Patient wears glasses.
RESPIRATORY: Normal breath sounds and respiratory effort. No chest wall deformities, tenderness or edema.
CARDIOVASCULAR: Normal sinus rhythm, no murmurs or abnormal heart sounds.
MUSCULOSKELETAL: Normal gait.
Cervical spine: normal inspection/palpation, ROM, muscle strength and tone, and stability.
Thoracic spine: normal inspection/palpation, ROM, muscle strength and tone, and stability.
Lumbar spine: Tenderness in midline at L5 - mild. No muscle spasm. No trigger point. Active ROM. Flexion -
asymptomatic but restricted to 25 degrees. Extension - restricted to 5 degrees. Right lateral flexion - restricted to 25
degrees. Left lateral flexion - restricted to 25 degrees; no pain when rotating hips; no pain when abducting hips.
SI joint: normal palpation and stability.
NEUROLOGIC:
Level of consciousness: awake and alert.
Mood and affect: normal and appropriate to the situation.
Cranial nerves: I - XII grossly intact and symmetrical.
Motor examination: Full and symmetrical muscle strength, tone and size throughout upper and lower extremities.
Deep tendon reflexes: 1+ throughout the upper extremities 1+ throughout the lower extremities.
ASSESSMENT
CURRENT PROBLEMS
722.52 Intervertebral disc disorders: Degeneration of lumbar or lumbosacral intervertebral disc
311 Depressive disorder, not elsewhere classified
729.1 Other disorders of soft tissues: Myalgia and myositis, unspecified
722.83 Intervertebral disc disorders: Postlaminectomy syndrome: Lumbar region
204.10 Lymphoid leukemia: Chronic The following fifth-digit subclassification is for use with category 204:
719.46 Other and unspecified disorders of joint: Pain in joint lower leg
Location: bilateral
719.45 Other and unspecified disorders of joint: Pain in joint pelvic region and thigh
Medical Advice: Avoid cigarette smoke. Conditioning program. Contact the office if there are any problems. Continue
with home exercise program as tolerated. Counseled to increase activity. Reduce weight.
Medication Notes: Viibryd 40mg one per day. Increase Neurontin 100mg one tablet in the morning and two at noon and
two tablets at bedtime. Patient is to continue MsContin 60mg one tablet every 8 hours, Zanaflex 4mg TID prn, Naprosyn
500mg one tablet BID with food, Protonix 40mg one tablet daily. Common medication side effects reviewed with the
patient.
Consults and referrals: Patient is to continue care with her hematologist for her chronic leukemia.
Schedule Follow-up: in 2 months.
Comments: 2013 ICD-10-CM Diagnosis Code M51.36
Other intervertebral disc degeneration, lumbar region
***722.52 converts to either M51.36 lumbar or M51.37 lumbosacral**** chose M51.36 based on exam
2013 ICD-10-CM Diagnosis Code F32.9 Major depressive disorder, single episode, unspecified 2013 ICD-10-CM Diagnosis Code M60.9 Myositis, unspecified2013 ICD-10-CM Diagnosis Code M79.1 Myalgia**separate codes for myalgia and myositis*** 2013 ICD-10-CM Diagnosis Code M96.1 Postlaminectomy syndrome, not elsewhere classified 2013 ICD-10-CM Diagnosis Code C91.10 Chronic lymphocytic leukemia of B-cell type not having achieved remission 2013 ICD-10-CM Diagnosis Code M25.562 Pain in left knee 2013 ICD-10-CM Diagnosis Code M25.559 Pain in unspecified hip*** or left and right codes***.
FU GENERALIZED PAIN TEST Chart #
DOB:
ICD CODE SUMMARY
722.52 Intervertebral disc disorders: Degeneration of lumbar or lumbosacral intervertebral disc
311 Depressive disorder, not elsewhere classified
729.1 Other disorders of soft tissues: Myalgia and myositis, unspecified
722.83 Intervertebral disc disorders: Postlaminectomy syndrome: Lumbar region
204.10 Lymphoid leukemia: Chronic The following fifth-digit subclassification is for use with category 204:
719.46 Other and unspecified disorders of joint: Pain in joint lower leg
719.45 Other and unspecified disorders of joint: Pain in joint pelvic region and thigh
CPT CODE SUMMARY
NON-BILLABLE CPT CODES
No non-billable CPT codes selected for this visit

Source: http://himss.cms-plus.com/files/WAVE%208/Med_Record_160_SID_180_Pilot_Test_Redacted.pdf