Chief Complaint - can you code

dmaec

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well, most everybody has a CC when they come in. But why would you code from the CC only? Why wouldn't you code the providers assessment? Did the provider not find anything? (no findings)... what's your scenario?
 

mpate

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scenario...pt comes in with chief complaint of knee pain. in the assessment provider does not give a dx...but he is ordering an xray of the knee and prescribes pain meds

would you code the 719.46 from the chief complaint (the patients own words)
 

dmaec

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I'd go back to the provider and ask them what the dx is, and have them amend their documentation to support the reason for the visit and the order for the xray - what's the xray order say? (dx reason for it) -
I would "assume" the knee pain, yes - and probably wouldn't have a problem coding the 719.46, but why didn't the provider document it in the assessement/findings? Is the pain mentioned in the ROS or EXAM?
 

Lisa Bledsoe

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You can code the knee pain, but remind your provider that he/she needs to provide a diagnosis in the assessment/plan to support the rest of the documentation and medical necessity. An unfriendly auditor will not infer that the dx is knee pain. Sounds like he/she just got a little lazy. They all do from time to time with the documentation and we just need to remind them of the importance of complete documentation - it's in their best interest!
 

codersumit

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In my opinion, it totally depends from one case to another. In a situation, where a condition documented under CC is documented under different areas like HPI, ROS, etc. then you would not mind considering it. however, if that is the only place it is documented then either you would want to report it with a disclaimer or would hold on and have your provider ammend it.
 

coder5254

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coding from CC

no where in CPT does it state the CC is a key component. You code from the key components, HPI, PE, MDM....nothing about CC

Go back to dr and get clarification..but never code from CC:)
 
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