3rd Qtr Physician 2016 Radiology Case Study #2- Spine
51 y/o M AETCT-PPO
Provider Specialty- Chiropractor
Request Initiated 06/13/2016
CPT: 72141 MRI Cervical Spine, (spinal canal and contents); without contrast material
ICD10: M54.12 Radiculopathy, cervical region
Nurse Reviewer Note:
Dr. Fizsimons/MDO/Chiro req MRI C-spine wo req neck pain that radiates down into left trapezius and left arm x 3 weeks prior to FOV
Reason or R/O: cervical disc herniation
FOV: 5/09/16 LOV: 5/31/16
PE: (+) Cervical compression that reproduces pain; no weakness but radicular pain pattern (C6)
PMH: (-) hx of injury, surgery or CA
TX: (5/09/16) Chiropractic, myofascial work and HEP and are ongoing
Prior imaging: (6/01/16) X-ray C-spine: mild degenerative changes with left foraminal narrowing at C5 and C6; patent on the right side.
ACDS Note Rev'd
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