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EM chief complaint used in medical decision making?

  1. #1
    Default EM chief complaint used in medical decision making?
    Medical Coding Books
    Can a chief complaint be used in the medical decision making? I have a situtation where the dx was listed in the chief complaint but only the treatment was listed in the decision making (assessment). The doctor didn't state the diagnosis he was treating but it is an established problem. Can I give credit for this diagnosis?

  2. Default explain
    Explain give credit for diagnosis? Give credit where? I am confused, cause the only way you can give credit is if there is 3 or more Chonic Diseases stated in the CC.

  3. #3
    Default explaination
    What I am questioning is the MDM number of diagnosis. This doctor may have a few dx he is treating but never mentions in his assessment & plan the actual dx. He only list the treatment.

    He does put a cheif complaint but never states in the assessment & plan the actual diagnosis. I can tell by the treatment he is doing that it does match the cheif complaint. I hope this is a better explaination.

    I was told you can't code your medical decision making from the HPI, ROS & PFSH. Does this mean the CC too?

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