Medical Billing Coding - Coding Chief Complaint with causal condition, cpt, codes
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Thread Topic: Coding Chief Complaint with causal condition
Topic Originator: Superbiller
Post Date June 3, 2011 @ 8:33 PM
Coding Chief Complaint with causal condition

June 3, 2011 @ 8:33 PM Reply  |  Email Friend   |  |Print  |  Top

Hi all!

I am having a real issue with this.  Rule of thumb is to code the chief complaint first, but what if the code for the chief complaint is one that says to code causal condition first if applicable?

The documentation will have why the patient came in, then during the visit the Dr. discovers the condition causing the sympton so he will list this code under assesment.  I keep getting corrections from our main office that I am listing the diagnosis's in the wrong order, but it clearly says in every coding book...if applicable code causal condition first!

Any suggestions?

June 3, 2011 @ 9:17 PM Reply  |  Email Friend   |  |Print  |  Top

I am not entirely sure what you are asking, but if a patient comes in for a chief complaint of a cough and during the visit the doctor diagnoses the patient with Bronchitis, you would not code the cough, just the bronchitis, since a cough is a symptom, and integral to the Bronchitis.

If I have missed what you are asking, let me know and I will try to help if I can.

June 3, 2011 @ 11:15 PM Reply  |  Email Friend   |  |Print  |  Top

Well we are a specialty practice. Urology. So for example, patine come in and chief complaint is urinary retention. Dr does the exam and discovers the patient has BPH (enlarged prostate). The code for retention clearly states in the coding companion (if applicable, code causal condition first). So I would code BPH as primary DX then the retention next.

We just started EMR and our billing office is saying I HAVE to code in the exact order the Dr. documented...and of course the first thing in the documentation is the chief complaint. I argued that it makes no sense whatsoever to code the symptom then the etiology. Isn't this correct?

Thanks for the help!

November 23, 2011 @ 9:52 PM Reply  |  Email Friend   |  |Print  |  Top

Yes it is proper to code the BPH 600.01 first then the symptom or LUTS (lower urinary tract symptoms).

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