Would I code as this scenario as exposure to hepatitis C, or does the documentation really support that? I question because the note seems to indicate the hep C is the patient's statement, which I'm not sure I can use as a certainty. Provider's note as follows.
S: "Employee got scratched by a patient who was in the office today. Pt had HIV test (negative) and patient said he had hepatitis C as well."
Basically, the pt just so happened to be in clinic to get test results, which included the negative HIV. Per the note, the employee was walking past the patient, who happened to trip right at that time, they bumped into one another, the pt accidentally scratched the employee.
The provider gave V65.44, HIV counseling, as the diagnosis and reason for tests. Tests ordered were CMP, hepatitis panel, syphilis, and HIV-1.
I am wondering if I should code V01.79, exposure to hep C, as primary diagnosis? Or, because it seems to be the patient's statement (not verified by doctor), can I use that? Is it "suspected" and thus not codeable? Shall I use what the provider gave (counseling)?
Thanks in advance! This board has been a wonderful resource for me!
S: "Employee got scratched by a patient who was in the office today. Pt had HIV test (negative) and patient said he had hepatitis C as well."
Basically, the pt just so happened to be in clinic to get test results, which included the negative HIV. Per the note, the employee was walking past the patient, who happened to trip right at that time, they bumped into one another, the pt accidentally scratched the employee.
The provider gave V65.44, HIV counseling, as the diagnosis and reason for tests. Tests ordered were CMP, hepatitis panel, syphilis, and HIV-1.
I am wondering if I should code V01.79, exposure to hep C, as primary diagnosis? Or, because it seems to be the patient's statement (not verified by doctor), can I use that? Is it "suspected" and thus not codeable? Shall I use what the provider gave (counseling)?
Thanks in advance! This board has been a wonderful resource for me!
