Using the techniques described in this chapter, carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s), if appropriate. Remember, check the chapter-specific, sub-chapter-specific, and category-specific notations within the Tabular List. HISTORY OF PRESENT ILLNESS: This patient is a 43-year-old male with pain in his cervical spine. He states that the pain extends over the entire posterior neck and into the right shoulder, including the upper trapezius. He rates that at a level of 7–8 on a scale of 10 currently. He states that at its least it is 3–4 on a scale of 10. The patient is using a cervical collar with good results. He also uses ibuprofen at night. This patient was involved in an MVA 5 years ago resulting in a fracture of C5. He had manipulation approximately 3 years ago resulting in pain for approximately 5 months. He had neck pain develop again approximately 18 months ago resulting in bilateral shoulder surgery. The pain has remained the same, although the numbness is better for approximately 1 year. He currently has complaints of a radial distribution into his left hand, wh ich caused him enough concern to seek intervention from Dr. Furmenn. The patient was then referred here.
Using the techniques described in this chapter, carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s), if appropriate. Remember, check the chapter-specific, sub-chapter-specific, and category-specific notations within the Tabular List.
HISTORY OF PRESENT ILLNESS: This patient is a 43-year-old male with pain in his cervical spine. He states that the pain extends over the entire posterior neck and into the right shoulder, including the upper trapezius. He rates that at a level of 7–8 on a scale of 10 currently. He states that at its least it is 3–4 on a scale of 10. The patient is using a cervical collar with good results. He also uses ibuprofen at night.
This patient was involved in an MVA 5 years ago resulting in a fracture of C5. He had manipulation approximately 3 years ago resulting in pain for approximately 5 months. He had neck pain develop again approximately 18 months ago resulting in bilateral shoulder surgery. The pain has remained the same, although the numbness is better for approximately 1 year. He currently has complaints of a radial distribution into his left hand, wh ich caused him enough concern to seek intervention from Dr. Furmenn. The patient was then referred here.
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