# ER Visit: Chief Complaint vs. 1st Diagnosis as primary?



## dreampeddler (May 8, 2009)

Hi Everyone!

A provider initially billed the following:
99284
Diag #1: 465.9  ACUTE URI UNSPEC         
Diag #2: 787.03 VOMITING ALONE 

Because of their contract, this prompted us to pay them a particular amount that's lower than a regular "emergent visit."

They then billed us again, and switched the codes, sending along the medical record for the visit.

That patient's "chief complaint" was vomitting, however, the first diagnosis listed in the record is URI, with #2 being vomitting.

Which of these is most appropriately used for the primary diagnosis?

Thanks!

Jodie S.
CPC


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## jimbo1231 (May 13, 2009)

*Vomiting*

The reason the patient came to the ED is generally coded first. If the patient came to the ED primarily because they were vomiting; and the ED doc determined that it was a symptom of a URI, the more emergent diagnosis would be acceptable since the ED physican had to respond to that complaintwith at least moderate MDM to determine what the cause was. For a 4 I would be looking for some intervention; IV fluids, labs, X-Ray, meds. If none of this was done it would probably be a 3.

Jim


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## MishCPC (May 25, 2009)

According to instructions in ICD09 manual, in Section IV (H) it states "List first the ICD9 code for the diagnosis, problem or other reason for the encounter shown in the medical record to be chiefly responsible for the services provided."

If the patient came to the ED primarily because he or she was vomiting, I would use vomiting as the primary dx.   Rule of thumb in ED coding is to use the reason for patient's visit to the ED  as a primary dx code.   HOpe that helps.


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## LTibbetts (Jun 16, 2009)

When I code ER's I code what the doc documented as the final Dx. If the vomiting was a sign or symptom of the URI, then it doesn't need to be coded at all. If it is an additional dx then I would code that as well, depending on how the physician sequenced them. What did the physician document as the primary dx? I would go by that.


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## mitchellde (Jun 16, 2009)

I agree with Leslie, it is considered redundant to code a symptom that is explained by the definitive dx.  However if the URI was not the cause of the vomiting and that is why the pt was there then I would do the vomiting first followed by the URI.


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