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Wiki coding from HPI

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Brenda1973

Networker
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94
Location
Sault Sainte Marie, MI
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Hello, this cellulitis diagnosis is from a Bee sting that is noted in the HPI. Can I add the bee sting to the diagnosis if the provider does not state bee sting in the diagnosis and it is only noted it the HPI?


Assessment/Plan
Medical Decision Making:

Diagnoses and all orders for this visit:
Cellulitis of right upper extremity
- sulfamethoxazole-trimethoprim (Bactrim DS) 800-160 mg tablet; Take 1 tablet by mouth every 12 (twelve) hours for 5 days.
Antibiotics prescribed due to:
ABX Reason: suspected bacterial infection
 
yes. It is a common misconception that you cannot code from anywhere other than the assessment/plan. If the provider signs the note, and the information is supported, then you can code it.
 
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