A 67-year-old established female patient was admitted to the outpatient surgery center for a
scheduled diagnostic arthroscopy of her right shoulder because of constant pain on rotation of the
shoulder. Prior to entering the operating room she told the nurse, "I have been feeling weak and
tired ever since my last visit." The surgeon performs a reexamination with a detailed history,
expanded problem-focused physical, and moderate-complexity decision making prior to the
surgery. The findings were negative and the diagnostic arthroscopy, right shoulder, was performed
uneventfully.
Procedure/Service: Arthroscopy, right shoulder. Enter code:
Diagnosis: Pain, right shoulder. Enter code:
Procedure/Service: Outpatient, established patient, expanded problem focused. Enter code:
Diagnosis: Weak and tired. Enter code: