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Coding of Chief Complaint

  1. Default Coding of Chief Complaint
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    To my knowledge we only code the diagnosis confirmed by the physician/medical practitioner. My question is do we code the chief complaint - the reason why the patient feels the need for the visit.

    For example : The nurse writes patient complains of sore throat.... but doesn't clarify anything further ..... Do we code this?

    Any help will be greatly appreciated as I am new to coding.

    Thank you.

  2. #2
    There should be something in the MDM coding from the HPI is wrong. They could say "sore throat". Once the examination/Tests are Performed it could be a totally diffrenent Dx. So really the Nurse was missing the MDM where the final Dx is made.

  3. Default chief complaint
    Always remember to code what is documented in the record and I agree with last response that you wait to see what results from tests. Physician will make final diagnoses from tests which is why he ordered them.

  4. Default
    Thank you.

  5. #5
    It might depend on the setting, but where I work (hospital outpatient) we code admitting DX, reason for vist DX, then also primary and any secondary DX.

    The first 2 can definitely come from the patient's complaints, whereas the latter 2 are from the Dr. and H+P...

  6. Default

    Exactly it depends on the setting as philgro said
    Nandha CPC

  7. Default
    Thank you

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