# Coding of Chief Complaint



## siddika_82@hotmail.com (Oct 8, 2010)

Hi, 

To my knowledge we only code the diagnosis confirmed by the physician/medical practitioner. My question is do we code the chief complaint - the reason why the patient feels the need for the visit. 

For example : The nurse writes patient complains of sore throat.... but doesn't clarify anything further ..... Do we code this?

Any help will be greatly appreciated as I am new to coding. 

Thank you.


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## AB87 (Oct 8, 2010)

There should be something in the MDM coding from the HPI is wrong. They could say "sore throat". Once the examination/Tests are Performed it could be a totally diffrenent Dx. So really the Nurse was missing the MDM where the final Dx is made.


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## christinebrownell (Oct 10, 2010)

*chief complaint*

Always remember to code what is documented in the record and I agree with last response that you wait to see what results from tests. Physician will make final diagnoses from tests which is why he ordered them.


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## siddika_82@hotmail.com (Oct 11, 2010)

Thank you.


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## philgro (Oct 13, 2010)

It might depend on the setting, but where I work (hospital outpatient) we code admitting DX, reason for vist DX, then also primary and any secondary DX. 

The first 2 can definitely come from the patient's complaints, whereas the latter 2 are from the Dr. and H+P...


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## Nandhakumar007 (Oct 14, 2010)

Hi..

Exactly it depends on the setting as philgro said


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## siddika_82@hotmail.com (Oct 18, 2010)

Thank you


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