Wiki Chief Complaint Confusion

Create Wiki Sort by date
L

lhoot

Guest
Messages
86
Location
Eldersburg, MD
Best answers
0
Good Morning,
Looking for feedback on a chief complaint. Since reason for appointment states the need for a diabetic foot exam, would the chief complaint be diabetes or should I pick up something else in the HPI?
Reason for Appointment
1. Pt needs referral for podiatrist for diabetic foot exam.
History of Present Illness
Patient came in order to be stablished, discuss his conditions,
adjust medications...Need evaluation with eye doctor because
glaucoma in right eye. Explain about diabetes mellitus
medications,advise low carbo diet,,,Follow up with labs

Laura
 
0
Are you asking what diagnosis you should pick as your first-listed code? If so, the guidelines say that you should choose "the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided." If the chief complaint is a need for a diabetic foot exam, then yes, I would choose diabetes since that is the condition from the documentation you've provided that is most closely associated with the stated reason for the visit.
 
0
thomas7331 said:
Are you asking what diagnosis you should pick as your first-listed code? If so, the guidelines say that you should choose "the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided." If the chief complaint is a need for a diabetic foot exam, then yes, I would choose diabetes since that is the condition from the documentation you've provided that is most closely associated with the stated reason for the visit.
Click to expand...

Thomas,
Thanks for such a quick response.
My apologies for not adding this bit of the question - I'm looking to find the code needed to list as the chief complaint/reason for visit. As for the whole encounter, yes, diabetes was the condition being addressed. The confusion comes when the chief complaint doesn't really correlate with a code which leaves me at a loss for what to use for reason for visit.
Thanks,
Laura
 
0
I guess I'm still not quite understanding what you mean. Are you asking about coding the 'reason for visit' section of an UB-04 on an outpatient facility claim? It doesn't necessarily have to correlate. If you can translate the patient's stated reason into a code, that's what I'd choose here, but there are cases where you cannot, in which case it's sufficient and appropriate to use the symptom or diagnosis that is 'chiefly response for the services' as the guidelines indicate. That field typically does not affect payment or benefit determinations and is just supplemental information.
 
You must log in or register to reply here.
Top