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Chief Complaint - can you code

  1. #1
    Default Chief Complaint - can you code
    Medical Coding Books
    can you code from the chief complaint?

  2. #2
    Location
    Duluth, Minnesota
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    1,133
    Default
    well, most everybody has a CC when they come in. But why would you code from the CC only? Why wouldn't you code the providers assessment? Did the provider not find anything? (no findings)... what's your scenario?
    Donna, CPC, CPC-H

  3. #3
    Default
    scenario...pt comes in with chief complaint of knee pain. in the assessment provider does not give a dx...but he is ordering an xray of the knee and prescribes pain meds

    would you code the 719.46 from the chief complaint (the patients own words)

  4. #4
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    I'd go back to the provider and ask them what the dx is, and have them amend their documentation to support the reason for the visit and the order for the xray - what's the xray order say? (dx reason for it) -
    I would "assume" the knee pain, yes - and probably wouldn't have a problem coding the 719.46, but why didn't the provider document it in the assessement/findings? Is the pain mentioned in the ROS or EXAM?
    Donna, CPC, CPC-H

  5. #5
    Location
    Greeley, Colorado
    Posts
    2,045
    Wink
    You can code the knee pain, but remind your provider that he/she needs to provide a diagnosis in the assessment/plan to support the rest of the documentation and medical necessity. An unfriendly auditor will not infer that the dx is knee pain. Sounds like he/she just got a little lazy. They all do from time to time with the documentation and we just need to remind them of the importance of complete documentation - it's in their best interest!

  6. #6
    Default
    In my opinion, it totally depends from one case to another. In a situation, where a condition documented under CC is documented under different areas like HPI, ROS, etc. then you would not mind considering it. however, if that is the only place it is documented then either you would want to report it with a disclaimer or would hold on and have your provider ammend it.

  7. #7
    Smile coding from CC
    no where in CPT does it state the CC is a key component. You code from the key components, HPI, PE, MDM....nothing about CC

    Go back to dr and get clarification..but never code from CC
    passionforcoding

  8. #8
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    the CC "is" part of the HPI ...
    {that's my opinion on the posted matter}
    Donna, CPC, CPC-H

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