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….