Health Information Management

Ask the expert: If a patient comes in with chest pain and has coronary artery disease (CAD), would you code the CAD and not the chest pain? If it were angina and CAD, I would code the CAD and then the angina, but does the same hold true for just chest pain?

HIM-HIPAA Insider, April 24, 2007

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A: If the patient presented with chest pain and the physician did not document a cause (e.g., gastroesophageal reflux disease, musculoskeletal or pleuritic chest pain, costochondritis, etc.), then the chest pain is the principal diagnosis. You would not use CAD, unless the attending physician indicated that it was the cause of the chest pain.

Sandy Sillman, RHIT, PAHM, DRG coordinator for Henry Ford Health System in Detroit, answered this question.For more information,click here

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