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Herpes Dx

  1. #1
    Default Herpes Dx
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    Hello,

    Would you please review the chart notes below & help to confirm the question & why: Can I added B00.89 - Other herpesviral infection?


    Provider submitted code: Vulvar lesion LESION OF VULVA N90.89

    CC: new patient, vulvar lesion, abnormal bleeding
    HPI: new patient visit and vulvar lesion. She is overall doing well. Recently out of 3 yr relationship and now with new casual partner. For last week has had intense itching and burning on the vulva. Was treated for a UTI thru urgent care but does not have dysuria. No improvement since completing antibitoics
    *Also compaining of new ocp causing irregular bleeding--she is accustomed to having 2 day menses but now on the low dose ocp her bleeding is much heavier--starting on third week of pills but not missing any pills.

    Physical Exam:
    GU: BUS wnl; there are small multiform open lesions on the posterior forchette and also near the urethra. vagina w/o erythema or atrophy, lesions or discharge; Cervix w/o CMT or lesions; uterus not enlarged, no masses or tenderness; adenexa w/o tenderness or masses.

    A/P: vulvar lesions, and abnormal bleeding on low dose ocp
    Lesion: herpes swab but will empirically treat her lesions---they are consistent with herpes. Rest of her STD screening is up to date
    *
    Other orders
    - norgestimate - ethinyl estradiol (ORTHO-CYCLEN, SPRINTEC) 0.25-35 mg-mcg Tablet per tablet; Take 1 tablet by mouth once a day.
    **
    pt was seen today for skin lesion(s). *
    Diagnoses and all orders for this visit:*

    Encounter for initial prescription of contraceptive pills
    - THINPREP IMAGING SYSTEM PAP & HPV MRNA E6/E7,C.TRACHOMATIS/N.GONORRHOE; Future
    *Vulvar lesion
    - CULTURE, HERPES SIMPLEX VIRUS (HSV), NON-BLOOD; Future
    *
    Other orders
    - norgestimate - ethinyl estradiol (ORTHO-CYCLEN, SPRINTEC) 0.25-35 mg-mcg Tablet per tablet; Take 1 tablet by mouth once a day.
    - valACYclovir (VALTREX) 1000 mg Tablet; Take 1 tablet by mouth 2 times a day for 10 days.

    Helen H.
    Last edited by tintin; 10-22-2018 at 04:16 PM.

  2. Default
    You need to delete this for personal health information.

  3. #3
    Location
    Columbia, MO
    Posts
    13,253
    Default
    you cannot add a dx code for a dx that has not been rendered. The diagnosis/finding the provider render was that the patient has a vulvar lesion. He order tests to see if it is a herpes lesion but you cannot apply a dx code for a test that has no result yet. I agree with the provider code for the lesion only.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Default
    I think A/P notes & med ordered.. are confirmed the Dx of herpes.

    A/P :
    herpes swab but will empirically treat her lesions---they are consistent with herpes

    And Medical orders:
    valACYclovir (VALTREX) 1000 mg Tablet; Take 1 tablet by mouth 2 times a day for 10 days.

  5. #5
    Location
    Columbia, MO
    Posts
    13,253
    Default
    I disagree.. Saying they are consistent with herpes is not a dx of herpes. I would advise to not code this as a rendered dx.

    Debra A. Mitchell, MSPH, CPC-H

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