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Thread: Coding from Cheif Complaint

  1. #1

    Question Coding from Cheif Complaint

    AAPC: Back to School
    I'm doing ER coding for our facility. The DR documented under the cheif complaint that a pt had a hip and lower back injury. The final DX is Lumbar Strain. Since he ordered an x-ray of the hip, this DX isn't going to be enough. Can I code from the cheif complaint as long as the DR wrote it or do I have to ask him/her to add it to the final DX list?



  2. #2
    Join Date
    Apr 2007


    Yes you can. The chief complaint is what brought them in and the final diagnosis was determine after the x-ray was done. So I would use theirchief complaint as their first code.


  3. #3


    Hi Jennifer,

    Remember that it is symptoms that bring the patient in and in order to arrive at a diagnosis (especially when the chief complaint is musculoskeletal in nature), x-rays are needed to both rule out and rule in firm diagnoses.

    To answer your question, it is perfectly acceptable to use the presenting symptom to justify an x-ray. Had they not done the x-ray, they would never have known if there might be an underlying fracture, lytic or blastic lesions, etc.

    If I were coding your scenario, it would look like this: 9928_ with the diagnoses of: 847.2 and 719.45

    Hope this makes a little bit of sense.

    Have a great evening,


  4. #4


    Thanks so much! I just wanted to make sure I wasn't doing anything that's against the guidelines. This will make coding and medical necessity so much easier!

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