Outpatient Facility Coding Alert

Question: My ED physician saw a patient for anterior wall chest pain. After examination, 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?

Tennessee Subscriber

Answer: Your first 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.

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. Refer to the Official Coding Guidelines I.C.18.a, I.C.18.b and IV.H for more information.

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