Wiki History Section of E/M

[LLRodgers]

Hello,

I just have a question: If a patent comes on and the doctor dictates Chief Complaint: Left Foot Pain can I use the pain as an Associated Sign or Symptom?

If not if they mention Pain in the History of Present Illness: can I use it as an Associates Sign or Symptom?

Thank you,

Linda

 

[AlanPechacek]

Lynda: Using "Foot Pain" as a Chief Complaint is fine, but "Pain (in the Foot)" is a symptom/complaint, not a diagnosis in and of itself. The "diagnosis" is what is determined to be the cause of the "foot pain." If the final diagnosis adequately accounts for the pain, then the "pain" is included in the diagnosis code for the disease/disorder, and "Foot Pain" would not also be listed in the list of diagnoses. If, however, there turns out to be no clear "diagnosis" to explain the pain, then the code for Limb Pain (M79.6 Code Set) could be used as a (temporary) diagnosis code. In this case, M79.67 _: Pain in Foot &/or Toes. If after the Workup/Evaluation process is completed (X-rays, CT's, MRI's, etc.) a clear diagnosis is made, then the Pain code would be removed, and replaced by the final diagnosis code.

Hopefully this helps you. I would also recommend your going to the Blogs Tab at my website, icd10orthocoder.com, and review the Blog on Coding for Pain.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com