Wiki How many diagnoses?

[kathymoon]

I think I already know this but I would like some verification from others. The provider sees the patient for recheck of COPD. HPI involves only COPD and O2 usage.
The ROS states sinus pain (HEENT) and decreased exercise tolerance (Respiratory).
Assessment and Plan: COPD, Chronic Rhinitis (continue med), Nerves (start med) Sinus congestion call if worsens). (The meds are listed in the A&P).

So my question: How many diagnoses do you actually count? Nothing documented regarding the rhinitis or the nerves. I am saying I would count the Sinus Congestion and the COPD.

Let me hear some other opinions.

 

[mitchellde]

It really depends on what was involved in the examination

 

[kathymoon]

addendum:

I really thought I had included the Physical Exam: ENMT everything was normal except "Sinuses - Bilateral - mildly tender to palpation.
Respiratory appropriate exam for the COPD and Cardio normal.

 

[terribrown]

We are instructed to code everything that was addressed at that time of visit. Appropriate ROS, OS in exam, and inclusion of final Dx with medication plan in assessment is enough to validate coding of both COPD and chronic rhinitis (note the instruction to "continue" med validating this is an ongoing issue this provider is addressing). I would query about the "nerves" Dx that required a new medication being prescribed, and then include that more specific Dx as well. (Is the provider referring to an emotional or a physical condition?) The extent of addressing these conditions determines the level of E/M...but the Dx are here and clearly these conditions were addressed to validate inclusion.