Wiki Encounter note documentation guideline help

[Brenda1973]

This is an outpatient telehealth encounter. Coding guidelines for outpatient services apply. Am I wrong to ask for an addendum as the outpatient guidelines clearly state that we cannot code a diagnosis as "suspected." We would have to code the signs and symptoms. This note is clearly stating Cellulitis, until the provider added the "suspected" verbiage into the plan. This is also AI and picking up unwanted words. I think its not acceptable. I would like others input please.



Assessment
- Cellulitis following insect sting

Plan
- Prescribed cephalexin for treatment of suspected cellulitis
- Draw a line around the area tonight before bed and take a picture to watch for changes in size
- Watch for any worsening, like more pain, redness, or swelling
- If fever or chills start, follow up in person for a checkup and blood test
- Follow up with the clinic if things get worse or do not get better, as medicine may need to be changed

Diagnosis Plan
1. Cellulitis of left lower extremity cephalexin (Keflex) 500 mg capsule

 

[TThivierge]

Hi
I d code it as it is......dx L03.16 and W57. It seems acceptable documentation. The provider is the expert and he assigns the dx .... it is Cellulitis as his best guess.
I hope I helped you
Lady T