tci ED Coding & Reimbursement Alert - 2004 Issue 4

Reader Question: Don't List Confusing Diagnostic Information

Question: A patient presents to the emergency department with a complaint of chest pain. The physician performs a complete history, review of systems, past family social history, physical examination, and cardiac workup. However, the only final diagnosis the doctor lists is anxiety. Since she based the workup on the complaint of chest pain, should I list "chest pain" as the primary diagnosis and "anxiety" as secondary, even though the doctor only listed anxiety as the final diagnosis?Utah Subscriber Answer: According to ICD-9 coding guidelines, "The documentation should describe the patient's condition, using terminology which includes the specific diagnosis...

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