HS292 Unit 7 Chest Pain Coding Seminar Reflection Example

Costochondritis, Reflux or Unspecified, and Then the Word Likely: A Unit 7 Seminar Reflection on One Emergency Department Chest Pain Note

[Student Name]

Purdue University Global

HS292: Billing and Coding Practicum

Unit 7 Seminar Reflection

[Instructor Name]

[Date]

The note, classmates and instructor are composite and described by role; the coding guidelines, code set and clinical guideline cited are real.

The Note

The instructor gave us one emergency department note before the session. A 41-year-old woman came in with left-sided chest pain that began the evening after she helped a friend move furniture. Her electrocardiogram and troponin were normal. On examination, pressing on the left costochondral junction reproduced the pain exactly. She was given an antacid in triage before the physician saw her. The assessment read: "Chest pain, likely musculoskeletal. Doubt cardiac. NSAID, follow up with PCP."

My Answer

I coded costochondritis. My reasoning felt solid at the time: the tenderness was at the costochondral junction, pressing reproduced the pain and the provider said musculoskeletal. To me, the physical finding made the diagnosis. I remember being a little impatient with the question, because it seemed easy.

Two Other Answers

A classmate who works in a pharmacy coded gastroesophageal reflux, reasoning that triage gave an antacid and antacids treat reflux. Another classmate, who said she prefers to be safe, coded unspecified chest pain.

When we laid the three answers side by side, the instructor pointed out that each of us had read a different line of the note as the diagnosis. I had read the examination. The pharmacy classmate had read the triage medication. The cautious classmate had read the first two words of the assessment and stopped.

The Turn

The instructor asked one question: "Which line is the provider's conclusion, and what word in it matters most?" The answer was the assessment, and the word was likely. In outpatient and emergency department coding, a diagnosis the provider qualifies as likely, probable or suspected is not coded as if it were confirmed; the coder reports what is certain, usually the symptom (National Center for Health Statistics, 2025).

The provider had not diagnosed costochondritis; I had, and the word likely was the provider telling me so.

That ruled out my answer, and it ruled out reflux even more firmly, since the provider never mentioned it. But it did not make unspecified chest pain correct. The note says more than unspecified: the pain is left-sided and reproduced by pressing on the chest wall. The code set has a category for other chest pain that includes anterior chest wall pain, which describes what the provider documented with more precision than the unspecified code (Centers for Medicare & Medicaid Services, 2025). That was the fourth answer, other chest pain [R07.89], and none of us had chosen it.

The cautious classmate's answer was safe in one sense and inaccurate in another. Specificity is part of accuracy. Choosing the vaguest code avoids overreaching but still reports less than the record supports.

What I Noticed About Myself

My mistake was not ignorance of the rule. I knew the rule about uncertain diagnoses. I did not apply it because I had already decided what the patient had. Reading the examination, I formed a clinical impression and then read the assessment as confirming it. Clinical guidance treats chest pain reproduced by palpation as suggestive of a musculoskeletal cause but not conclusive on its own (Gulati et al., 2021), which is presumably why the physician wrote likely rather than a firm diagnosis. The physician was being careful, and I was not.

What I Do Now

I have adopted a small habit since the seminar. Before choosing any code, I find the assessment and circle every qualifier: likely, probable, possible, suspected, rule out, consistent with, compatible with. Then I ask whether the setting is outpatient or inpatient, because the rule differs. Only after that do I read the rest of the note for specificity, such as side, site and cause. Over the following week I applied the habit to the twelve practice notes in our workbook and found two more where I had coded a qualified diagnosis as confirmed.

A Question I Still Have

If a provider writes "costochondritis" without a qualifier but documents nothing more than tenderness, should a coder question whether the diagnosis is supported? I think the answer is that coders do not second-guess clinical judgment, but I would like to hear how working coders handle a diagnosis that seems thin. My guess is that the answer involves a clinical validation query rather than a coder's own judgment, which would keep the decision with the physician while still raising the concern. I plan to ask our practicum supervisor at the next check-in, and to bring the chest pain note as the example, since it is the case that taught me how quickly a reader can turn a likely into a diagnosis.

References

Centers for Medicare & Medicaid Services. (2025). ICD-10-CM tabular list of diseases and injuries FY 2026. U.S. Department of Health and Human Services.

Gulati, M., Levy, P. D., Mukherjee, D., Amsterdam, E., Bhatt, D. L., Birtcher, K. K., Blankstein, R., Boyd, J., Bullock-Palmer, R. P., Conejo, T., Diercks, D. B., Gentile, F., Greenwood, J. P., Hess, E. P., Hollenberg, S. M., Jaber, W. A., Jneid, H., Joglar, J. A., Morrow, D. A., . . . Shaw, L. J. (2021). 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 144(22), e368-e454. https://doi.org/10.1161/CIR.0000000000001029

National Center for Health Statistics. (2025). ICD-10-CM official guidelines for coding and reporting FY 2026. Centers for Disease Control and Prevention.