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Wiki Coding from H&P

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tlindo1

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Williams Bay, WI
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If a patient has HTN in their H&P and they are taking medication for their HTN. If there is no mention of HTN in their assessment but blood pressure was taken and documented, can HTN be coded?
 
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I am not taking dx from HPI. final diagnosis should be taken from Assessment/Plan. for Example, if the patient reason for visit is BP check and provider taken Blood pressure reading and documented final diagnosis code as Z01.30 -Encounter for examination of blood pressure without abnormal findings in Assessment/Plan. In this case i can code Z01.30 based on A/P. I hope it helps
 
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tlindo1 said:
If a patient has HTN in their H&P and they are taking medication for their HTN. If there is no mention of HTN in their assessment but blood pressure was taken and documented, can HTN be coded?
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No, you can only code what's in the note - unless they happen to state something like " see H+P for details"
 
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