Wiki "most likely" herpes simplex infection

[tag60]

Outpatient visit. Doctor gives a diagnosis but also states "most likely" -- those words make this an uncertain diagnosis and thus do not code, correct?

CC: Child brought in by mom with cold sores that developed around mouth and inside lips for the past week. Painful when touched. No fevers.

Skin exam: Erythematous vesicular bumps at right corner of mouth. Apthous ulcers inside of lips.

Dx: Herpes simplex infection.
Advised most likely herpes virus. Self-limiting. Given viscous lidocaine for pain. Advised not to rub area and to drink plenty of water. Follow up in 2-3 days if not improving.

I considering coding apthous ulcer, K12.0, which covers exam description of lips. But what about the vesicular bumps at corner of mouth, the cold sores? Index leads to B00.1, herpesviral vesicular dermatitis...but provider states most likely. I'm confused!

Perhaps I'm overthinking this. How would you code the above note?

Thanks in advance!

 

[djrice86]

I understand the rule; however, the way it's documented here, it says on the Dx line, "herpes simplex infection." The "most likely" part was in reference to conversation with the patient. Personally, I would code the herpes simplex infection. However, I can see the argument for the opposite too (coding just the symptoms). I think this is a defend-able judgement call either way.