Question

Assessment
 1. Left shoulder pain (M25.512)
Left shoulder pain for about 6 months, pain with rotator cuff muscles. No weakness
    compared to right. I have suspicion for rotator cuff, specifically supraspinatus
    tendinopathy. We discussed conservative measures at home and will order physical
    therapy to vertical motion. Additionally we will get a left shoulder x-ray for baseline.
    Ultimately, discussed MRI if symptoms are worsening or not improving with physical
    therapy
 2. Hyperlipidemia (E78.5)
He does get an annual cholesterol screening through his insurance with Lifeshare and
    reports improvement in cholesterol labs with dietary changes. Last records in our office
    with LDL of 143 in 2020.
    We will order a coronary calcium CT to further stratify his risk. He will follow-up based on
    these results.
   

Plan
 TSI - HEART CORONARY CALCIUM CT - 401T; Status:Need Information - Financial
Authorization; Requested for:22Mar2024;
 TSI - SHOULDER XRAY MINIMUM OF 2 VIEWS LT- 1778T; Status:Active; Requested
for:22Mar2024;
   
Chief Complaint
   
shoulder pain

History of Present Illness
   
a 59-year-old male presenting today for shoulder pain. No previous injuries to this shoulder or surgeries. Left shoulder pain present since August. No specific injury, but does notice pain is worse with overhead lifting motions and push-ups. He has tried resting and avoiding these activities, although pain persists. Pain is located in the left, top and back of shoulder. Painful when reaching out for a cup of coffee. no perceived weakness or pain that radiates. Denies neck pain or neck stiffness. Denies grip strength weakness.

Additionally, he would like to order a coronary calcium CT. He had a friend that recently had 1 and had significant blockage. He does get an annual cholesterol screening through his insurance with Lifeshare. Last records in our office with LDL of 143 in 2020. No cardiac symptoms, no dizziness, chest pain or SOB with exertion.

Review of Systems
   
Constitutional, eye, otolaryngeal, cardiovascular, pulmonary, skin, neurological and psychiatric review of systems are normal except as noted.  
Musculoskeletal: arthralgias and joint pain.  
Neurological: no limb weakness.  



Physical Exam
   
Appearance: Normal no AC joint hypertrophy, no AC joint step-off, no deformity, no ecchymosis and no swelling. Tenderness: AC joint, but not the bicipital groove, not the proximal clavicle, not the midshaft clavicle, not the distal clavicle, not the deltoid, not the humeral neck and not the scapula. Palpatory findings include no crepitus. Pain with palpation of the posterior shoulder along supraspinatous attachment at the posterior humeral head. ROM: Full. Forward flexion: painful restricted AROM 90 degrees. Motor: Normal. Forward flexion was painful. Abduction was painful. Special Tests: positive Neer test, positive Empty Can test and positive Lift Off test.
 
Constitutional
General appearance: No acute distress, well appearing and well nourished.   
Pulmonary
Respiratory effort: No increased work of breathing or signs of respiratory distress.   
Musculoskeletal
Gait and station: Normal.  
Inspection/palpation of joints, bones, and muscles: Abnormal.  see above.  
Psychiatric
Orientation to person, place and time: Normal.  
Mood and affect: Normal.  

Current Meds:Medication reconciliation occurred to include current, discontinued, and post-hospital discharge medications. Note: New medications or modifications to current medications found in the plan section of the note. For any dosing changes and new medications started, the risks and benefits were discussed with the patient.
Medication Name
Instruction
Omeprazole 20 MG Oral Tablet Delayed Release
Take 1 tablet daily
   

   

Active Problems
 1. Acute sinusitis, unspecified (J01.90)
Acute sinusitis, unspecified
 2. Barrett esophagus (K22.70)
Esophagitis, unspecified
 3. Contact with and (suspected) exposure to other viral communicable diseases (Z20.828)
 4. Encounter for general adult medical examination with abnormal findings (Z00.01)
Encounter for general adult medical examination with abnormal findings
 5. Eosinophilic esophagitis (K20.0)
per EGD patho 8/19/2021
 6. Family history of ischemic heart disease and other diseases of the circulatory system
 (Z82.49)
Family history of ischemic heart disease and other diseases of the circulatory system
 7. Occlusion and stenosis of unspecified carotid artery (I65.29)
Occlusion and stenosis of unspecified carotid artery
 8. Osteoarthritis of left knee (M17.12)
 9. Polyp of colon (K63.5)
Polyp of colon
 10. Pure hypercholesterolemia (E78.00)
Pure hypercholesterolemia
   

   
what charge do i use 99213 or 99214