# DX code sequence



## Lizz B (Apr 15, 2012)

I'm totally confused. I understand you code the dictated diagnosis versus symptoms. Scenario is: patient presents with chest pain, has EKG done which is neg. and then EGD which reveals acute gastritis and final discharge note is "chest pain due to acute gastritis" .  So would it be correct to use acute gastritis as primary dx and chest pain as secondary to justify the EKG?
Sorry, I've never coded dx for ER and find it a little confusing! Any help would be appreciated. Thanks.


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## mitchellde (Apr 15, 2012)

no you would not code the symptom once it is deemed to be due the gastritis, you could though use the V71.7 first followed by the gastritis to show observation for suspected cardiovascular disease not found.  which would give you what you need for the EKG, follows correct coding guidelines, and sequencing rules, and would match the documentation, assuming the documentation can support the supposition of possible cardiovascular issue.


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## Lizz B (Apr 15, 2012)

*dx code confusion*

Debra, thanks so much!  Your answer makes perfect sense!  I wish the ICD-9 coding book was as clear as your answer (or maybe it is, somewhere in the hundreds of pages!)


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## jimbo1231 (Apr 15, 2012)

*Depends*

I would agree on the facility side. But many ED coding and billing entities would take the position that the syptom of chest pain is coded first. The argument is that this is the reason the patient came to the ED. Also frankly, it's a stronger diagnosis than gastritis for payment. Some don't agree, but this is the approach taught by most ED billing/coding entities on the physician side.

Jim


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## mitchellde (Apr 15, 2012)

however the coding guidelines tell us differently, the guidelines tell us that we are not to code the symptoms with the definitive dx that explains the symptoms.  In fact if you think about it, the chest pain is not what brought the patient in, it was the gastritis, the patient just did not know how to express that and could only express the symptom.    This is why the V71 code category comes in handy for situations like this.  It works on the physician side as well.


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## jimbo1231 (Apr 16, 2012)

*True, But*

Agree that is what the guidelines dictate. But pretty much all ED physician billing/coding entities will go with the symptom of chest pain in that scenario. The argument is that is the primary reason the patient came to the ED. Since ED visits are unsceduled the emphasis is on the reason the patient is there since the ED since physician must act based on the presenting problem. I'm not saying I agree necessarily, but use of symptoms has withstood many audits.

Jim


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## mitchellde (Apr 16, 2012)

I understand but the correct way is to use the V71.7 first listed with the gastritis secondary.   I know that many do things out of habit and or convenience, I feel our job as certified coders is to try to correct this when we see it.


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## jimbo1231 (Apr 17, 2012)

*OK*

I said I didn't disagree. But the symptom coding is not done out of habit and convenience. It's the approach the ED coding/billiing industry generally takes. This includes, in their practice, the people who designed the CEDC. Anyway I'll graciously end the discussion here by saying again that per the guidelines I agree with you.


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