Where is it written


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Here is a good question that was presented to me:

Where is it written, in other words LAW, that the primary diagnosis must be the chief complaint or reason for visit?

Can anyone find the answer---I need proof positive for this doctor.
Yes--I wouldn't go as far as to call it "law," but it is a stated guideline, per ICD.

Check out, Section IV, (Diagnostic Coding and Reporting Guidelines for Outpatient Services), part A, (Selection of first-listed Condition), and point 1 under that sub-section. Also, part H, same Section gives the overall application for services "other than" outpatient surgery.

The third paragraph under "ICD-9-CM Official Guidelines for Coding and Reporting" also touches on the marriage of ICD rules to a law: HIPAA.

Anyhow, I hope this is what you're looking for and wish you luck in your endeavor.

Thank you so much for the information--this doctor wants the information in black and white--the ICD-9 guidelines are too too too grey!!!

I appreciate your effort and will try it but doubt it will work.
Well then, you can try the UACDS: Uniform Ambulatory Care Data Set (equivolent to UHDDS).

I believe the language is far less "gray." I must say, I never knew that providers consider ICD (in any part) to be "gray" matter. Of note, CMS is one of the cooperating parties for ICD, which I would imagine would carry some weight in the provider community.

Hopefully this will help.

Good luck.
I agree 100% with Kevin on this subject.

Is your physician possibly thinking that if the patient comes in, for example, abdominal pain - but it's determined by the end of the examination that the patient has gastroenteritis... Is your doc still unsure if abdominal pain must be coded primary?
Hello Kevin, Your answer confuses me. In Section VI, letter H, it goes on to say to list first the ICD-9 code for the diagnosis, condition, problem or other reason for the encounter/visit shown in the medical record to be "chiefly responsible" for the services provided. This may not always be the ICD-9 code that describes the chief complaint or reason for the visit. How do you respond to this statement?

I code for a physician's and surgeon's office. I know hospital coding has separate coding issues in their coding order.

Thank you
Mary Baierl, CPC, CCA, CMT
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That section I referenced does not have application just to the hospital environment. It is for any outpatient service--including surgeries and/or clinic visits.

Perhaps I am misunderstanding your objective; I thought you were asking where it was printed that the primary reason for the encounter be listed as "first listed" (e.g., Primary) diagnosis. To my knowledge, there is no restriction written anywhere that says the presenting problem must be the primary diagnosis.

For instance, a patient may present with a chief complaint of "sore throat." The physician examines the patient, determines through a series of lab tests and a culture that the patient actually has Streptococcal tonsillitis. In that case, you assign the appropriate code for strep tonsillitis, in lieu of a code for sore throat, as the symptom (sore throat) is integral to the disease process.

In the OP realm, diagnoses are coded based on certainty, rather than IP rules. Regardless of what your presenting problem/chief complaint, you would code to the actual reason for the encounter--which very well may be different from your presenting problem.

I didn't mean to confuse you. Perhaps this will help.

If you're asking something different than what I infer, maybe someone else can chime in and offer insight.

Good luck.
I agree with your response. I did some checking too in the ICD-9-CM coding manual as well as the CMS website. While there are some rules for coding the primary diagnosis when the individual is the interpreting physicians of diagnostic test data, I couldn't locate anything specific to the physician addressing the patient's visit itself.

The only area where I think this could be an issue (and this would depend on insurer and laws in our respective states) is E/D diagnosis coding on the professional side for states with a prudent layperson law. In that case, it may be prudent to list the chief complaint followed by the final diagnosis. It typically matters to those insurers who use diagnosis editing on E/D visits to deny the inappropriate use of the E/D. The trend now is to recognize the E/D visit but apply the member's copay to the visit.