A 12-year-old boy is seen in the physician’s office for a sore on his lip. The patient is new to the physician and physician group. A detailed history indicates the patient has been otherwise healthy and is current on immunizations. An expanded problem-focused examination is performed. The physician documents herpes simplex infection of the lip and prescribes an antiviral medication.

What diagnosis and procedure codes would you report for this encounter? What procedure code would be reported if the patient were established to the physician?

The International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for the encounter is 054.9, herpes simplex without mention of complication. When reporting with International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), the location of the lesion is the key to determining the correct code. The alphabetic index for ICD-10-CM includes the sub-terms labialis and lip under the main terms of herpes, herpesvirus,...

You do not currently have access to this content.