Wiki Herpes Dx

[tintin]

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.

 

[michellepilcher]

You need to delete this for personal health information.

 

[mitchellde]

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.

 

[tintin]

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.

 

[mitchellde]

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.