Wiki Diagnoses for MDM level of service

[MargoR]

Hello all, Question.
If a provider documents multiple chronic issues are being managed to the same area, do you count them as one or multiple.
Example: Patient diagnosis as per documentation 1. shoulder pain 2. OA to shoulder 3. tendinitis to shoulder

Coding I would code only the definitive diagnosis, but in auditing this is where I'm stumped. My provider states they are separate, if anyone can assist and if you have a resource to back up your answer.
Thank you all.

 

[NRaizman]

I wouldn't count a general diagnosis like "Shoulder Pain" when a more specific diagnosis exists, but tendinitis and osteoarthritis are separate diagnoses, and if they are supported by the documentation then they are legit. They just both lead to shoulder pain and have significant overlap in a lot of patients.

 

[TThivierge]

HI
I always thought abstract code according to medical specialties or body groups in variety suffered by patient and if new vs established problem. Is this incorrect?
Lady T

 

[MargoR]

Thank you.