Wiki high risk sexual behavior

[karen.long@ihs.gov]

I work for a family practice facility. They say they have standing orders for certain diseases (HIV, HEPATITIS C, ETC) for certain patient in between ages 20 something to their 40's or 50's. They are giving them high risk sexual behavior diagnosis. I don't think this should be used especially if their notes state they aren't sexually active or have only had 1 partner in the last 5 to 10 years. Can someone help me with this?

 

[thomas7331]

The code choice has to reflect what the provider documents in the record as being the patient's diagnosis and/or the reason for ordering the test. So if they are not documenting that the patient engages in high risk behavior, then no, that code should not be assigned or used. Codes should not be assigned just based on a standing order - codes need to reflect what is in the individual patient's record. However, if they are documenting that the patient has high risk behavior but you are questioning this diagnosis based on other information in the record that seems contradictory, then this is something you would need to discuss with the providers, or query them to add clarification to their notes so that you can be sure the coding is correct and supported by the medical record. Hope this helps some.

 

[karen.long@ihs.gov]

Thank you so much!!!

Karen