An established 47-year-old patient presents…
An established 47-year-old patient presents to the provider’s office after falling last night in her apartment when she slipped on water on the kitchen floor. She is complaining of low back pain and no tingling or numbness. Provider documents that she has full range motion of the spine, with discomfort. Her gait is within normal limits. Straight leg raising is negative. She requested no prescription medication. It is recommended to use heat, such as a hot water bottle. Take Ibuprofen as needed for pain. Provider’s Assessment: Lower Back Muscle Strain. What E/M and ICD-10-CM codes are reported for this service?