Results 1 to 4 of 4

Coding from Cheif Complaint

  1. Question Coding from Cheif Complaint
    Medical Coding Books
    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
    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. Wink
    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. Smile
    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!

Similar Threads

  1. What is the Cheif complaint?
    By peanutbutterkisses in forum Medical Coding General Discussion
    Replies: 22
    Last Post: 04-03-2015, 07:20 PM
  2. Coding only the Chief Complaint
    By fnk001 in forum Diagnosis Coding
    Replies: 1
    Last Post: 02-12-2015, 01:26 AM
  3. Cheif complaint in the Encounter
    By almag69 in forum E/M
    Replies: 0
    Last Post: 10-04-2013, 09:41 AM
  4. med refill as a cheif complaint?
    By pineapplelvr in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 05-25-2011, 01:55 PM
  5. Coding of Chief complaint
    By coder5254 in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 09-24-2008, 08:50 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.