You've got a challenge here. There may be specific verbiage in your provider contracts to this effect, but otherwise check the CMS 1997 and 1995 documentation guidelines. There is also usually a state statute that talks about minimum documentation requirements. Look for something that says regulation Of Medical Professions or something similar in your state legislature site.
I would speculate that is the BP is consistently high, and is documented as HTN earlier in the chart, then billing HTN is ok. It makes a difference in how the doc makes decisions, regardless of the tx itself (medically managed).
If there is no definitive diagnosis, then using the symptoms or previous diagnosis is appropriate billing.
I hope that helps.
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