Revenue Cycle Insider

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 note that osteoarthritis and tendinitis are separate diagnoses; make sure that you have the documentation to support each diagnosis. Both diagnoses can cause shoulder pain, and there may be overlap for many patients.

With that in mind, it’s important to code what the provider documents and to query for clarification if you have questions.

Separate diagnoses may support a higher level of medical decision making (MDM). However, you don’t mention whether the patient was new or established, or whether the shoulder issues diagnosed during this encounter or were previously diagnosed, or if the issues are acute or chronic. That information would be necessary to determine the specific E/M codes.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC