Presenting problem vs diagnosis
The problem I have with this is that the "presenting problem" or chief complaint, is NOT the diagnosis. It's what the patient says is wrong.
I may say I have a sore throat, but only the physician's exam and expertise will diagnosis this as tonsilitis or strep throat or thrush or "just a cold."
I do not downcode based on the presenting problem. I will downcode if the MDM doesn't meet the level of service that the exam & history show.
It's a subtle but important difference.
Hope that helps.
F Tessa Bartels, CPC, CEMC