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Chief Complaints
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Neck Pain and Stiffness
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NP&S Subfield
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Association with
• • •
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Thoracic Pain, Stiffness and Spasm
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TPT&S
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Lower Back Pain & Stiffness
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LBP&S Subfield
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Association to
• • •
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Pain
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Pain Subfield
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Pre Existing Complaints
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General Appearance
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Normal
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Not Normal
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Not Normal Subfield
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Physical Examination
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Physical Exam : Patient Amb
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Trigger points and Muscle spasms
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Head & Neck General
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Inter-Spinal Ligament Injury
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Thoracic Spine
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(Bilateral) Facet and Myofascial whiplash pain with Muscle spasm and stiffness
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(Left) Facet and Myofascial whiplash pain with Muscle spasm and stiffness
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(Right) Facet and Myofascial whiplash pain with Muscle spasm and stiffness
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(Left) Sacroilliac Joint Pain Injury
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(Right) Sacroilliac Joint Pain Injury
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(Left) Shoulder
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(Right) Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hip
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Right Hip
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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RANGE OF MOTION TESTING
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Range Of Motion Testing
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Cranial Nerves 2-12
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Degrees + @
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Left Sensory Examination ARMS
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Right Sensory Examination ARMS
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Left Motor Examination
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Right Motor Examination
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Motor Exam Upper
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Left Sensory Examination LEGS
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Right Sensory Examination LEGS
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Motor Exam Lower
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Assessment
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Post Traumatic Headaches
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Post Traumatic D&B Issues
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Post Traumatic Concussion Syndrome
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Post Traumatic Cognitive Disorder
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Post Traumatic Depression/Anxiety
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Cervical Myosfascial Derangement-Whiplash Injury
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Cervical Facet Syndrome
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R/O Cervical Disc Herniation with neck pain
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Cervical Degenerative disc with neck pain
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R/O Cervical Radiculopathy
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Left Cervical Radiculopathy
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Right Cervical Radiculopathy
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Thoracic Myofascial Pain-Whiplash Injury
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Thoracic Facet Joint Pain
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Thoracic Degenerative bulging disc with pain
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R/O Thoracic Disc herniation with pain
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Lumbar Whiplash-Myofascial Pain
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Lumbar Facet Syndrome-Pain
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R/O Lumbar Radiculopathy
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R/O Lumbar Disc Herniation with back pain
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Left Lumbar Degenerative disc with Radiculopathy
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Right Lumbar Degenerative disc with Radiculopathy
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Lumbar Degenerative Disc with back pain
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Left Sacroilliac Joint Sprain
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Right Sacroilliac Joint Sprain
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Left Sacroilliac Joint Disruption
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Right Sacroilliac Joint Disruption
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Left Post Traumatic TMJ Disorder (Jaw Joint)
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Right Post Traumatic TMJ Disorder (Jaw Joint)
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Post Traumatic Inter Spinal Lig Injury
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Left Shoulder Strain/Tendinitis
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Right Shoulder Strain/Tendinitis
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(Left) R/O Shoulder Int Derang
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(Right) R/O Shoulder Int Derang
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Left Shoulder Int Derangement
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Right Shoulder Int Derangement
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Left Shoulder Rot Cuff Tear
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Right Shoulder Rot Cuff Tear
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Left Elbow Sprain
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Right Elbow Sprain
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Left Elbow Tendon Tear
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Right Elbow Tendon Tear
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Left Elbow Joint Injury
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Right Elbow Joint Injury
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(Left) Post Traumatic Carpal Tunnel Syndrome
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(Right) Post Traumatic Carpal Tunnel Syndrome
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Left Wrist Sprain
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Right Wrist Sprain
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Left Hand Sprain
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Right Hand Sprain
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Left Hip Sprain
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Right Hip Sprain
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Left Hip Tendon/Muscle Tear
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Right Hip Tendon/Muscle Tear
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Left Hip Labrum Tear (Int Derng)
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Right Hip Labrum Tear (Int Derng)
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Left Knee Sprain
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Right Knee Sprain
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Left Knee Internal Derangement
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Right Knee Internal Derangement
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Left Knee Joint Injury with pain
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Right Knee Joint Injury with pain
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Left Ankle Sprain
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Right Ankle Sprain
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Left Foot Sprain
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Right Foot Sprain
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Other
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Pre existing Vs New
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Procedure Details
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Procedure Details
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Patient's Consent
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Procedure Note
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Procedure Note
• • •
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Area Injected
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Area Injected
• • •
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Medical Necessity of Ultrasound guided injections
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Disability
• • •
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Causal Relationship (DOA)
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Signature of provider
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Initial Visit
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99202 expanded focused history (20mins)
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99203 Detailed History (30mins)
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Follow Up
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99212 Established Patient (10mins)
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99213 Established patient (15min)
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Small Joint Intra-articular injection
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Ultra Sound guidance
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X
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Intermediate Joint Intra-articular injection
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Large Joint Intra-articular injection
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Trigger Point of muscle ( 1-2) Muscles
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Trigger Point of muscle (3-4) Muscles
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Single Tendon Sheath / Ligament
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INJECTION RELATED ICD-10 CODE
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Other
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Other ICD 10 Codes
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Other ICD 10 Codes
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Plan of care
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Chiropractic Physical-Therapy Treatment
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Renewal of Physical Therapy - Chiropractic
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Home Exercise Program
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Refer to
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Neurologist
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Refer to
• • •
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Neurologist for
• • •
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MRI Arthogram
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MRI Arthogram
• • •
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MRI Ordered
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X-ray
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Cervical
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Lumbar
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Brain MRI
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Days headache have not improved for?
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Prescription
• • •
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Follow Up 3-4 weeks
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Follow up 1-2 week
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