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Wiki Atypical chest pain

lindacoder

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Northeast Kansas AAPC
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Patient admitted with atypical chest pain. Patient had roux-en-Y gastric bypass in 2006. Prior to our consult patient underwent EGD by another physician which showed retained food in his pouch which "probably" accounts for the atypical chest pain. Would you only use the chest pain diagnosis and not even mention post roux? Thanks for any suggestions!
 
I would only code what is documented in the notes for this encounter. If the chest pain is the reason for the encounter and there is no causal relationship indicated in the documentation for this encounter, I would only code the chest pain.
 
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