Outpatient Progress Note · Physical Medicine & Rehabilitation
Signed & Locked 18-Sep-2026
Patient: Vargas, Elena M.
DOB: 12-Apr-1979 (Age 47)
Encounter ID: ENC-20260918-0914
Provider: Marcus Vance, MD (NPI 1999999999)
Subjective / Chief Complaint
Patient returns for evaluation of persistent right knee pain and gait instability following bilateral meniscus wear. Reports symptoms worsen with stair descent (pain visual analog scale 4/10 to 7/10). Patient has completed 6 weeks of independent home exercise therapy without sufficient functional restoration.
Conservative Therapy History & Step Failures
| Trial 1: Oral NSAID | Meloxicam 15 mg daily x 8 weeks. Discontinued due to secondary gastric distress and refractory morning stiffness. |
| Trial 2: Home Exercise | Documented home physical therapy exercises 3x weekly x 6 weeks. Failed to improve quadriceps recruitment index. |
| Trial 3: Injection | Right knee intra-articular corticosteroid injection administered 14-May-2026. Provided transient 4-week relief before symptom return. |
Assessment & Clinical Diagnoses (ICD-10)
- M17.11 — Primary osteoarthritis, right knee
- G89.4 — Chronic refractory pain syndrome associated with degenerative arthropathy
Plan & Orders for Skilled Rehabilitation
Continued skilled outpatient physical therapy indicated to restore gait mechanics and stabilize knee extension. Prescribed formal physical therapy 2x weekly for 6 weeks (total 12 sessions).
CPT 97110 (Therapeutic exercise, 1+ areas, each 15 min) — 12 units
CPT 97530 (Therapeutic activities, dynamic movement) — 8 units
Frequency: 2 sessions/week x 6 weeks · Rendering NPI: 1999999999
Clinical Rationale for Payer Prior Auth: Documented failures of conservative management (failed 8-week oral NSAID trial due to adverse GI effect + transient response to steroid injection). Continued skilled intervention required to prevent surgical arthroplasty candidate escalation.