New Patient Office Visit · Sarah Johnson · Dr. Michael Carter
Encounter ENC-2026-118420
42-year-old female presents with 14 months of progressive right knee pain, worse with stair climbing and prolonged standing. Reports morning stiffness lasting 20 minutes and intermittent swelling. Has tried OTC NSAIDs and 6 weeks of home exercise without lasting relief. Denies locking, trauma, fever, or night pain.
Vitals: BP 122/78, HR 74, BMI 27.4. Right knee: mild effusion, medial joint line tenderness, crepitus with ROM, flexion 0–120°. Ligaments stable; McMurray negative. Antalgic gait. Radiographs (3 views): medial joint space narrowing with subchondral sclerosis and marginal osteophytes, Kellgren-Lawrence grade 3.
1. Unilateral primary osteoarthritis, right knee (M17.11) — radiographically confirmed KL grade 3, symptomatic > 12 months, failed conservative therapy. 2. Chronic right knee pain (M25.561 / G89.29).
Intra-articular corticosteroid injection of right knee performed today under sterile technique (20610-RT). Continue NSAIDs as tolerated, initiate formal physical therapy 2×/week for 6 weeks, weight-management counseling provided. Follow up in 6 weeks; discuss viscosupplementation or arthroplasty referral if symptoms persist.
NetRev AI documentation hint
Your assessment supports M17.11 with radiographic grading and symptom duration — strong medical-necessity language. Add the specific conservative therapies attempted to further protect the 20610 line on audit.
Unilateral primary osteoarthritis, right knee
Pain in right knee
Other chronic pain
Office visit, new patient, moderate complexity
Arthrocentesis, major joint — knee injection
Radiologic exam, knee, 3 views
Meloxicam 15 mg
1 tab PO daily with food
Qty 30 · Refills 1
Methylprednisolone acetate 40 mg
Intra-articular, right knee — administered
Qty 1 · Refills 0
Acetaminophen 500 mg
PRN pain, max 3 g/day
Qty OTC · Refills —