4th Qtr 2016 Medicare Nursing Case Study #1
52yof-MRI Lt shoulder wo (73221)
CG/HLTHSPNG AL NONIPA MCR (AL)
Per: web / mdo R/T: Left shoulder pain Duration: since 10/16/2016 Reason: Rotator cuff tendonitis with impingement. Possible rotator cuff tear, left shoulder
FOV: 10/16/2016 LOV: 10/24/2016
PE: Shoulder range of motion reproduces pain in forward flexion and abduction. Pain and weakness secondary to pain with rotator cuff testing and abduction and external rotation.
PMH: n/a surg hx. no surgery noted trauma hx. no trauma noted hx. of Ca. no cancer noted
TX: No treatment noted
Prior Imaging: /Member Hx:X-RAY 10/16/2016 No acute bony or soft tissue abnormalities. No fractures, etc. No degenerative change
NURSE Comment: 6 weeks conservative treatment with re-evaluation would be helpful in processing this request
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