Subsequent Hospital Services

[calorom2]

If a patient presents at the initial hospital services with chest pain and at the subsequent hospital service visit the chest pain is resolved would I still use the chest pain diagnosis? All that is indicated is that the patient is still nauseated, no chest pains and impression is non cardiac.

 

[wbrodsky]

If it is just a normal follow-up encounter, then I would only use nausea as the Dx code. If testing is being done alongside the E/M then I would still use the chest pain to show why the test(s) are being done.

 

[calorom2]

Thank you!