Gastroenterology Coding Alert

Question: An established patient comes into the reports to the gastroenterologist complaining of severe stomach cramps, trouble swallowing, and a "burning throat." The gastroenterologist performs a level-three E/M, prescribes antacids and rest, and sends the patient home. Do I need to choose one of these symptoms to list as the chief complaint (CC), or can you have multiple CCs? Illinois Subscriber Answer: CC is typically defined as a concise statement in the notes that describes the patient's problem, condition, diagnosis, or other factor that is the reason for the visit. This can be one or more symptoms that prompt the patient's presentation, and can include: • illness • injury • psychiatric conditions • normal bodily process that the patient perceives as abnormal • patient's perception of the problem. All the patient's presenting problems qualify as CCs, so you should list cramps (789.06, Abdominal pain; epigastric), swallowing difficulty (787.20, Dysphagia, unspecified), [...]