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Ahmed Al-Rashidi·Al Salam Cooperative Insurance·ENC-260915-2101

Clinical noteThe note will be read against the payer’s rules.

ServiceDiagnosis (ICD-10-AM)

QtyUnit price (SAR)Service date

Authorization required

From the payer’s rules for this service. Attach each document here, or state the facts in the note.

DocumentationPhysical exam findings
In the note exam findings
DocumentationSymptoms 4 weeks or more, or acute trauma
In the note symptom duration, acute trauma
DocumentationPrior conservative treatment documented
In the note conservative therapy
DocumentationReferring physician license no.
In the note referrer licenseAttach Referral letter
CriterionSuspected internal derangement, or failed 4-week conservative therapy
In the note derangement suspicion, conservative therapy
CriterionNo contraindication to MRI
In the note no mri contraindication

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