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E/M Coding:

Separate Diagnoses Can Support MDM Leveling

Question: A provider sees a patient and documents these diagnoses after the encounter: shoulder pain, osteoarthritis of the shoulder, and tendinitis of the shoulder. As a coder, I realize that in this encounter, shoulder pain is not a definitive diagnosis, and I wouldn’t list it as a primary diagnosis. Should I include it anyway? Georgia Subscriber Answer: It’s important to [...]
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