Wiki Coding of Chief Complaint

[siddika_82@hotmail.com]

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.

 

[AB87]

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.

 

[christinebrownell]

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.

 

[siddika_82@hotmail.com]

Thank you.

 

[philgro]

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...

 

[Nandhakumar007]

Hi..

Exactly it depends on the setting as philgro said

 

[siddika_82@hotmail.com]

Thank you