# Chief complaint help please!



## mimzmac (Feb 8, 2016)

Hi,

I need help with the chief complaint please. If the triage nurse writes " Restraint passenger* Involved* In MVA 3 car involved* pt was in middle car* . Complaints of head and neck pain* Denies any loc ." What would be your chief complaint? 

Another one is "Patient arrived via BLS from home s/p mechanical fall.* Patient arrives to ED on backboard and in c-collar.* Patient hit head on furniture.* Denies head, neck or back pain.* Denies LOC". What would be the chief complaint? 

Pt arrived via rescue after alleged assault.Per rescue pt is a school bus aid, large autistic child became violent. Struck pts head on window then punched the back of her head several times. Pt denies LOC. Denies use of blood thinners. Denies pain. Supervisor told pt to go to ER for eval." What would be your chief complaint?

Your assistance would is greatly appreciated!
Thank you very much.
Mimz


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## C Clark CPC CEDC (Feb 8, 2016)

*Chief Complaint*

Coding Scenario 1: Head/ Neck Pain
MVA: Passenger

Coding Scenario 2:  Head INJ (NOS)
Hit head on furniture

Coding Scenario 3:  Head INJ (NOS)
 Assault: Head

Disclaimer: Without seeing the actual documentation it's difficult to give a precise Chief Complaint suggestion.

Hope this helps..

Caprice Clark, CPC,CEDC


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## mimzmac (Feb 8, 2016)

Thank you for replying. 

I agree to all 3 answers but unfortunately the auditors that I work with doesn't agree with me. I was told to use senario 1: MVA; senario 2: Fall; senario 3: Alleged Assault. 

The points are higher if I used all these complaint instead of what the patient is really complaining rather than using the mechanism so we ended up charging higher. 

I'm trying to look for a regulations regarding this but I'm having such a hard time. Do you have any?

I really appreciate your time and input.

Thank you.
Mimz


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## mitchellde (Feb 8, 2016)

The external causes cannot be used as principle dx codes.  You can find this in the coding guidelines.  
Scenario 1:
The CC is the head and neck pain and after exam the principle dx will be the pain or injury documented then the code for the restrained passenger in an MVA
Scenario 2:
You have no injury to code and cannot use injury unspecified, your CC will be the fall but your principle dx code will be what the provider documents as any injury or the Z04.- code for evaluation following other accident with the fall secondary.
Scenario 3:
Again you have the CC of assault but no injury has yet been detected.  Again the principle dx will be either an injury after exam or the Z04.- with the assault cide secondary.
Your question was specifically for the CC which does not always become the principle dx code.


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## NeoCoder116 (Feb 9, 2016)

I agree with the answers given, i.e. Head Inj...

Unfortunately, a lot of coding in my opinion has to do with where you are coding and for whom it is being done, as the interpretation of those folks might not be in line with the consensus. I have to listen to a lawyer with no coding experience explain to me why they disagree with my findings in ICD-10. It can be frustrating but it is your coding certificate and just make sure you protect it because whatever code you append, you will have to answer for it. Good luck!


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## mitchellde (Feb 9, 2016)

You cannot code a head injury without the provider stating that a head injury is present.  Since you asked about the chief complaint, from the information given in two of the cases you had no chief complaint indicated other than an incident occurred. The provider will need to document whether an injury in n fact exists since the patient indicates there is no issue.  The coder cannot be the one that determines an injury does exist.  An external cause can be the chief complaint, however they cannot be the principle diagnosis.  If after exam, the provider determines that no injury exists, then the reason for the encounter, the chief complaint, is to evaluate for the possibility of an injury and there is none.  That is why the Z04 code is there, to indicate that there is no injury.  The coding rules do not change with whom you are coding for, you just need to remember to not read too much into it. Just because a fall occurred does not mean there is a resultant injury NOS.


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## C Clark CPC CEDC (Feb 9, 2016)

*Chief Complaint*

Sorry I should of clarified I was referring to the location of the injury "head"... not as  a diagnosis code.
In one of coding scenario's however you did indicate patient had head/neck pain

I agree with Mitchell... if a patient comes to E/R with no injuries documented..   refer to external code(s) (cause/activity etc )


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