EM Coding Alert

Question: My ED physician saw a patient for anterior wall chest pain. After he checked him out, he suspected that the patient may have gastroesophageal reflux disease (GERD). He wrote the final diagnosis as “chest pain, rule out GERD.” I’m not sure what my principal diagnosis should be. What should I report using ICD-10?

Pennsylvania Subscriber

Answer: Your code should be R07.89 (Anterior chest wall pain NOS). Codes that describe symptoms and signs are acceptable when your provider has not established a definitive diagnosis.

Rule of thumb: You should not code a disease or condition unless the provider makes a definitive diagnosis. If the physician performs tests to rule out a diagnosis and the diagnosis is not established when you submit the claim, you should only code the chief complaint, or signs and symptoms related to the “rule out” or “possible” diagnosis.

Bottom line: For outpatient encounters, do not code diagnoses documented as “rule out.” You should code the condition to the highest degree of certainty for that encounter. Don’t give a patient a diagnosis that hasn’t been confirmed (in this example, the GERD).

Reference: You should refer to the Official Coding Guidelines I.C.18.a, I.C.18.b and IV.H.