An established patient who had undergone an arthroscopic anterior cruciate ligament reconstruction on the right knee (29888) 4 weeks earlier visited the orthopedic surgeon complaining of pain in the left knee. He indicated the right knee was healing well and he was doing well since starting physical therapy. After an expanded problem-focused history and examination, the physician diagnosed fluid on the left knee and recommended a trial of an antiinflammatory drug. The physician discussed arthrocentesis with the patient and suggested if the patient's left knee were not better in 3 weeks, it would be wise to move forward with the procedure. The complexity of the decision-making was moderate. What code(s) should be reported in this case?
Added by Crystal L.
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The patient is experiencing fluid on the left knee, which is the main issue addressed during this visit. Show more…
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