CASE 6
Office note:
RE: Injection, strapping of foot and ankle.
Chief complaint: heel pain, 6 months' duration. No inflammation, no heat.
Diagnosis: Heel spur.
Treatment: Weight reduction, injection of Celestone, Xylocaine plain, pulses good, DTR,
vibration and temp normal.
Orthotics suggested; better shoes suggested. Lawyer by trade. Criminal trial attorney. Referred by his partner. Discussed diet, orthotic shoes. Return if need be in 61 days.
What diagnosis code(s) are reported?