Wiki Coding from H&P

[tlindo1]

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?

 

[dineshkumar.p7@accesshealthcare.com]

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

 

[Cmama12]

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?

No, you can only code what's in the note - unless they happen to state something like " see H+P for details"