Coding osteoarthritis without imaging to support it on established patient

SheryM

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Question: When billing a office visit for chronic pain medication refill- the HPI says patient had a previous injury to the shoulder and had a surgical repair, patient is over 65 yrs old and doctor diagnosed patient with with OA of the shoulder, but there is no imaging to support this Dx. Is it ok to code this on the ' Assumption" that the patient has this, due to the previous injury and the patient s age, or should the provider take a x-ray to support the dx?
 
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If the provider feels the diagnosis is supported based on his/her evaluation of the signs, symptoms, and history, then there would be no need for further testing. It sounds like the provider is confident in the DX.
 
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