ICD-10-CM Inpatient Coding Insight: Determining the Principal Diagnosis – Chest Pain vs. Neurological Symptoms

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Case Discussion:
In this inpatient case, a 43-year-old Black female with a significant past medical history—including diabetes, hypertension, prior tumor resection, asthma, and COPD—was admitted with chest pain and neurological symptoms, specifically left-sided weakness (hemiparesis).

The patient's chest pain was noted after back pain and was radiating to the left side. The provider initially considered TIA and MI, but both were ruled out in the discharge summary.

The coder raised an important question regarding the correct principal diagnosis (PDX)—whether it should be chest pain (R07.89) or potentially a neurological condition due to the hemiparesis.

Summary of Findings:

  • Principal Diagnosis Currently Assigned:
    R07.89 – Other chest pain

  • Secondary Diagnosis:
    G81.94 – Hemiplegia, unspecified affecting left nondominant side

  • Clinical Note: Left-sided hemiparesis occurred in association with back pain, but no confirmed etiology is documented for either the chest pain or neurological symptoms.

Coding Guidance & Clarification:

As per ICD-10-CM and coding guidelines, when there are multiple potential principal diagnoses and no definitive etiology is documented, coders must query the provider for clarification, especially when symptoms overlap and no clear cause is stated.

Recommended Queries:

  1. Etiology of chest pain – Was it cardiac, musculoskeletal, or possibly neurological in nature?
  2. Cause of neurological symptoms – Was the hemiparesis due to a stroke, TIA, or another condition? Or was it ruled out as a transient symptom without known cause?

Why a Query is Crucial:

  • TIA and MI are both ruled out, leaving no confirmed diagnosis for the chest pain or hemiparesis.
  • Without definitive documentation, symptom codes (like R07.89 and G81.94) are appropriate, but determining which one is the primary reason for admission requires clarification.
  • Depending on the provider’s response, the PDX could shift from chest pain to a neurological diagnosis or another underlying cause.

Pro Tip:
Until the provider responds, review the DRG options based on both R07.89 and G81.94. The final DRG may be impacted by which condition is selected as PDX and whether the hemiparesis qualifies as a CC.

Conclusion:
This case underlines the importance of querying providers when documentation is unclear, especially in cases with overlapping symptoms and multiple ruled-out diagnoses. Accurate principal diagnosis selection ensures compliant and optimize coding.


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