Gastroenterology Coding Alert

Question: An established patient comes into the reports to the gastroenterologist complaining of severe stomach cramps, trouble swallowing, and a "burning throat." The gastroenterologist performs a level-three E/M, prescribes antacids and rest, and sends the patient home. Do I need to choose one of these symptoms to list as the chief complaint (CC), or can you have multiple CCs?

Illinois Subscriber

Answer: CC is typically defined as a concise statement in the notes that describes the patient's problem, condition, diagnosis, or other factor that is the reason for the visit. This can be one or more symptoms that prompt the patient's presentation, and can include:

• illness

• injury

• psychiatric conditions

• normal bodily process that the patient perceives as abnormal

• patient's perception of the problem.

All the patient's presenting problems qualify as CCs, so you should list cramps (789.06, Abdominal pain; epigastric), swallowing difficulty (787.20, Dysphagia, unspecified), and sore throat (462, Acute pharyngitis) as the patient's CCs on this 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) claim.

Remember: CC is best gleaned from the patient's own words, so scour the notes for direct quotes from the patient, such as "My stomach cramps up a lot, and my throat is always sore, which makes it hard to swallow."