ED Coding and Reimbursement Alert

Question: A patient presents to the emergency department with a complaint of chest pain. The physician performs a complete history, review of systems, past family social history, physical examination, and cardiac workup. However, the only final diagnosis the doctor lists is anxiety. Since she based the workup on the complaint of chest pain, should I list "chest pain" as the primary diagnosis and "anxiety" as secondary, even though the doctor only listed anxiety as the final diagnosis?

Utah Subscriber

Answer: According to ICD-9 coding guidelines, "The documentation should describe the patient's condition, using terminology which includes the specific diagnosis as well as symptoms, problems, or reasons for the encounter." Medicare gives an example of a similar patient who presents with chest pain and after a cardiac workup is determined to have gastric reflux disease. The direction given is to code first the chest pain and second the gastric reflux.

A second issue here is that your physician did not actually include chest pain in the final diagnosis. Because of that omission, a safe approach would be to use this patient's chart for educational purposes and feedback to the physician. You should query the physician regarding the clinical relevance of the presenting complaint of chest pain, because if writing that down is only clouding your picture of what happened -- not illuminating it -- you don't need to get confused with extraneous information.

And, many groups of emergency department physicians have, as part of their compliance plan, specific designations about which portions of the chart are available to the coder for diagnosis coding. You may want to meet with your group to establish a protocol for this type of situation so no one feels confused or stuck in a diagnostic tight spot.