Emergency Room profee Diagnosis Coding

I’m hoping someone can help settle an ICD-10 coding debate regarding the first listed diagnosis for Emergency Room diagnoses.

Scenario: Patient presents with what the patient describes as chest pain, ED provider performs cardiac work-up, EKG and other applicable testing.

In the assessment and plan the provider notes:

Impression: GERD

Provider supplies an rx for Protonix and advises patient follow up with with primary physician in a few days.

Would the first listed diagnose be for chest pain or would it be for GERD?

CMO “Chief Medical Officer” who also has the designation of CCO “Chief Compliance Officer" of our billing company insists that in the example given above the primary or first listed diagnosis should be chest pain as this supports the cardiac work-up and EKG.

The reasoning behind this stance is that the terms "Impression or Assessment” indicate a physicians best guess at a diagnosis and therefore the terms do not indicate a definitive diagnosis and the presenting symptom of chest pain should be the first listed diagnosis. The CMO/CCO’s position is that the first listed diagnosis should be the one that best supports the services provided and allows for a higher level of E/M service to be billed.

The rational cited for this position in found on page 102, letter G. of the 2016 ICD-10-CM guidelines which states:List the first listed diagnosis, condition, problem, or other reason for encounter or visit shown in the medical record to be chiefly responsible for the services provided List all additional codes that describe any coexisting conditions. In some cases the first listed diagnosis has not been established (confirmed) by the physician.

Opinion are very much appreciated


  • edited May 2017

    Here’s my opinion for what it’s worth…….when a patient presents with symptoms that drive the need for medical intervention and testing, that diagnosis should be used to prove medical decision making to perform.

    The end result is from the findings, which may or may not coincide with the decision to perform.

    In other words, the physician has the right to justify the need for an exam or test, based on the patient’s symptom and use that as the reporting diagnosis. Those decisions for CPT and diagnosis correlation for reimbursement are written by physicians as being the most probable direction to take to determine a final diagnosis.

    Although physicians can be quite good at a spot-on diagnosis, sometimes the patient (and their symptoms) can fool them…….and the end result of the findings can be something entirely different.

    Just my opinion,

    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219-0409

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com

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