How would you factor in additional diagnosis for the MDM that are given in the assessment/plan, when these are not documented in the HPI/Exam of why the patient is coming in? For example, an elderly patient is coming in for knee joint pain and then in the assessment/plan the provider lists Hypertension(refilled meds), Gastroenteritis(wants labs done), Glaucoma(referral given), Diabetes(checks A1C) in addition to the joint pain.

My understanding is that you would not use any of these additional diagnosis to level the MDM, even though for each dx the provider wants more work up done.

I’m looking for feedback on what others are doing when a provider adds additional diagnosis and how the MDM is determined.