1. Strain of supraspinatus muscle
S46.012D: Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, subsequent encounter
PHYSICAL THERAPY SHOULDER REFERRAL – Schedule Within: provider’s discretion

2. Strain of subscapularis muscle
S46.012D: Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, subsequent encounter

3. Chronic kidney disease due to type 2 diabetes mellitus
E11.22: Type 2 diabetes mellitus with diabetic chronic kidney disease
GLYCOHEMOGLOBIN, TOTAL, BLOOD – To be performed on or around 12/08/2018
BMP, BLOOD – To be performed on or around 12/08/2018
LIPID PANEL, SERUM – To be performed on or around 12/08/2018

4. Hypothyroidism –

E03.9: Hypothyroidism, unspecified
levothyroxine 137 mcg tablet – TAKE 1 TAB DAILY MONDAY-SATURDAY, 1/2 TAB SUNDAY Qty: 28 tablet(s) Refills: 1 Pharmacy: CVS/PHARMACY #6510
TSH, SERUM OR PLASMA – To be performed on or around 12/08/2018

Discussion Notes
Will refer to PT and have Pt f/u in the next month. Informed her that an injection was not appropriate this close to the last and would likely not help as she has more than one tendonopathy. Pt given lab order which should be completed the week prior to her next visit.

I am going back and forth as far as counting the Chronic Kidney disease due to type 2 diabetes mellitus and the Hypothyroidism for the Medical Decision Making. There is no HPI relating to either of these diagnoses. Patient came in for the shoulder issue and that is all that is addressed in the History and Exam. It appears the provider ordered the lab work so he would have it for the patient’s future visit, and possibly the patient needed a refill on medication. I know I need to query the provider, as need to know the status of each of these diagnoses. However, if the sole purpose was ordering the lab work, do I even need to consider these two diagnoses in the MDM?

Thanks, in advance, for your assistance.