The patient was admitted for chest pain. Cardiology documents demand ischemia, but the discharge diagnosis list still shows only chest pain with no conclusion from the workup. What should the coder recognize?
Select an answer to reveal the explanation.
Short Explanation
Chest pain is the doorbell; demand ischemia may be what was found inside. If cardiology already named the finding but discharge still only lists the symptom, you have unfinished business—clarify before you crown a principal diagnosis.
Full Explanation
When a more definitive diagnosis is documented during the stay but the discharge diagnosis remains an unresolved symptom, coders should clarify which condition meets principal-diagnosis criteria. Admission symptoms do not automatically remain principal after study, and automatic replacement without reviewing the full discharge documentation is inappropriate.