Wiki E&M coding w/o diagnosis

[nina_930]

My physician documented in the assessment part of his note and billed a diagnosis of shoulder pain, however he also diagnosed osteoarthritis in his x-ray results. Since there is a definitive diagnosis, I know this should be replacing shoulder pain. If the note gets audited, will the pain dx be valid?
Thank you!

 

[thomas7331]

My physician documented in the assessment part of his note and billed a diagnosis of shoulder pain, however he also diagnosed osteoarthritis in his x-ray results. Since there is a definitive diagnosis, I know this should be replacing shoulder pain. If the note gets audited, will the pain dx be valid?
Thank you!

It may seem self-evident that the osteoarthritis is the source of the shoulder pain, but if the physician did not document this link then I would not make the assumption, and I would leave the pain diagnosis as the primary diagnosis since it is the principal reason for the visit and a definitive diagnosis was not given in the encounter note. Osteoarthritis may be used as a diagnosis for the x-ray.