Regarding which diagnoses to use - code diagnoses that are being treated, or which impact the treatment plan. Sometimes the physician needs to connect the dots better as a coder cannot interpret that a diagnosis simply listed is impacting the treatment plan.
For example, Let's say your same patient above is having a visit with a surgeon regarding a hernia considering surgical treatment. Surgeon writes "Recommend laparoscopic umbilical hernia repair for reducible hernia. Advised patient to closely monitor glucose levels 2 weeks prior and 2 weeks post surgery to ensure optimal healing." I would then use a DM diagnosis as the DM can impact the risk and treatment.
I think your clinician is not documenting clearly in some situations. Even though a patient may be following an endocrinologist for DM, a PCP may still be monitoring, renewing rx, ordering related labs, etc. I also ask my clinicians to list problems as chronic or acute (or indicate the amount of time - for past 2 weeks, the last 6 months, > 1 year, for years, since 2003, etc) to avoid any potential misunderstandings.
Until we got to item 4, the "cont current meds" and "cont current BP meds" is to me, an opportunity to educate your clinician about documentation. Unless there is additional documentation, I would not count that as prescription management. A note that says "continue labetelol 100mg BID for BP" I would count as prescription management. Item 4 does give prescription drug management. However, I don't think diazepam was prescribed due to history of bladder cancer. I'm no clinician, but that just seems incorrect.
1) HTN - being treated - discussed meds, labs, diet & exercise - I would code for it.
2) DM II - not really being treated, I would not code for it. Opportunity for physician education. Perhaps the diet education provided also addressed this. "Excellent control" could mean the clinician reviewed HgA1c ordered by endo, but not documented well.
3) CKD - being addressed - labs discussed - I would code for it.
4) Hx bladder cancer. I don't see documented where this was treated, addressed, or impacts care. Again, I think the diazepam listed here is under the wrong heading. Opportunity for physician education.
5) Other. Sometimes there is a general education topic that is important to a clinician. Like maybe most patients get this handout as a preventive education. If this was given due to insomnia, or fatigue, or daytime sleepiness, or some other reason, that's another opportunity for physician education.
In my opinion, level 2 is definite undercoding here. For leveling, I would count problem as moderate for 2 or more chronic stable problems. I am assuming the labs discussed were ordered and counted at a prior visit. Data is minimal. Risk is also moderate for prescription management of diazepam. This gets you an overall level 4.
Whenever leveling, it's helpful to list WHY you think a code is a particular level. MDM is based on 2 of 3 for problem, data and history. Determine the level for each to get your overall level.
Edit: It dawned on me that CKD and DM II are considered related, even if not explicitly stated so. So rather than N18.9, look at E11.22. NOT my area of expertise - but look into it if you're coding for primary care.