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E&M diagnosis chief complaint?

  1. Default E&M diagnosis chief complaint?
    Medical Coding Books
    I recently read an article that stated on the initial office visit to use the chief complaint diagnosis first and the physician's rendering diagnosis second. I am a little confused because if the patient comes in with radiographic studies and the physician can actually render an informed diagnosis, should we not use or list the confirmed diagnosis first?

  2. #2
    Kansas City, MO
    I tend to only use the ICD-9 guidelines when it comes to diagnosis coding.

    Section 1, Item 6. Signs and Symptoms - Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not be established (confirmed) by the provider.

    If you have a diagnosis at the end of the visit, it is all that is needed. If not, use signs and symptoms. They are normally stated in the chief complaint and carried through the documentation. I would be very wary of following advice that differs from the actual guidelines.
    Angela Jordan, CPC, COBGC, AAPC Fellow
    Senior Managing Consultant
    Medical Revenue Solutions, LLC
    AAPC National Advisory Board - Southwest
    AAPCCA BOD Chair 2012-2013

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