tci E/M Coding Alert - 2015 Issue 11

You Be the Coder: Coding 'Rule Out' Diagnoses

Question: My ED physician saw a patient for anterior wall chest pain. After he checked him out, 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 using ICD-10? Pennsylvania Subscriber Answer: Your 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. Rule of thumb: You should not code a disease or condition...

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