Osteoarthritis shoulder

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Hello! I have a physician that has documented in his HPI: Has had right shoulder surgery, with follow up with ortho later today David PA-C. She is having PT.

Coded this a M19.019 Primary Osteoarthritis, Unspecified Shoulder

History: Patients reason for surgery, repair of a rotator cuff tear.

I feel this isn't enough documentation to code osteoarthritis or is it?

Either I'm having a bad week or my providers documentation is awful....
 

Pam Brooks

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You can't assume osteoarthritis as the cause of the rotator cuff tear. Was it a traumatic tear?

I would not code osteoarthritis unless the provider specifically says so.
 
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The provider coded Primary Osteoarthritis, not myself. That's the reason for my inquiry as I wasn't sure if the documentation in the HPI was ok to apply the DX to this visit. So since the doctor specifically coded it in the A/P Osteoarthritis its all good. Fairly new at this so I just want to be sure.
 
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mitchellde

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If the only place the OA is documented is in the A/P with the dx code then no I would not code it. Coding Clinics 2012 1st quarter states the provider must document the dx in their own words and cannot use the dx code with the standard code description as the rendered dx.
There is no way to know if the provider selected the incorrect code in the system. or if the patient has a previous dx of OA.. it seems odd to documented a post surgical encounter for the rotator cuff repair but then in the assessment select the code for OA. I would not code the OA, but I would query the provider.
 
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