Gastroenterology Coding Alert

Question: A patient comes into the gastroenterologist with complaints of upper GI pain, uncontrolled belching, and unusual stomach noises. Do I need to choose one of these symptoms to list as the chief complaint, or can you have multiple CCs?

Idaho Subscriber

Answer: Chief complaint (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 being abnormal, or

• patient's perception of the problem.

All the patient's presenting problems qualify as CCs, so you should list esophagitis (530.1x, Esophagitis ...), belching (787.3, Flatulence, eructation, and gas pain), and "stomach sounds" (787.5, Abnormal bowel sounds) as the reasons for the visit. CC is best gleaned from the patient's own words, so scour the notes for direct quotes from the patient that indicate the CC symptoms.