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Thread: Coding of Chief Complaint

  1. #1

    Default Coding of Chief Complaint

    AAPC: Back to School

    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. #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. #4


    Thank you.

  5. #5
    Join Date
    Apr 2007


    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. #6



    Exactly it depends on the setting as philgro said
    Nandha CPC

  7. #7


    Thank you

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