Physician 1st Quarter 2016 Radiology IRR Case Study #5 – Spine
38yoF AETGA FI-PPO
Provider Specialty: Orthopedic Surgery
Request Initiated: 01/20/2016
CPT: 72141 - MRI Cervical Spine, (spinal canal and contents); without contrast material
ICD10: M54.2 - Cervicalgia
Nurse Reviewer Note:
Per webuser/ACDS/ortho-surg req MRI C-spine w/o for 38yoF c/o MVA on 10/06/2015. She was rear-ended, restrained. Airbag did not deploy, no LOC. She has persistent neck issues that do not radiate. C/O decreased ROM and stiffness. Feels she is getting a grinding in her neck. Reason: Neck pain.
FOV: 11/22/2015
LOV: 01/18/2016
PE: Diminished rotation and flexion/extension of her C-spine.
PMH: Hx of CA and spine surgery not provided.
TX: Ibuprofen, tramadol, tizanidine since FOV.
Prior Imaging: X-ray C-spine 11/22/15 - No fractures or dislocations.
ACDS note reviewed.
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