Wiki Which diagnosis code to use?

[Snflwr]

Pt was seen by PA who ordered xrays, in PA dictation his diag is arthritis of the shoulder (not mentioning what kind of arthritis), the doctor of which he practices under who reads the xray and dictates the finding states osteoarthritis of the shoulder. Who's diagnosis should I use for the office visit and xray? Thanks

 

[sbicknell]

The DX for the xray is based on the Radiologist's interp and written report. If he documents OA of the shoulder that's what is coded for the xray

The OV is coded based on the physician's findings, MDM and what he knew for a certainty at the time of the visit.

This 1st visit the physician may not have had the final Rad report and all he could say for a certainty was arthritis. When the patient comes back for a f/up and the physician has seen the Rad's report then he can say that based on the report he knows it is OA

The DX doesn't have to stay the same. Over the course of eval and treatment, the DX can become more specific or change