Chief Complaint and HPI

[daubert]

If a note does not contain a Chief Complaint or an HPI on an established patient, but has a detailed exam and moderate MDM, is it billable since you only need two of the three compontents for an E/M level?
Cindy

[RebeccaWoodward*]

I wouldn't allow it. The DG's state...

The documentation of each patient encounter should include:

• reason for the encounter and relevant history, physical examination
findings and prior diagnostic test results;

!DG: The medical record should clearly reflect the chief complaint.

Not providing the chief complaint creates an issue for medical necessity. It would be difficult to justify a detailed exam with moderate MDM (your example) with the absence of a CC. The CC paints a picture for the reason of the visit and illustrates the complexity.

[Eagle Eye]

I agree with Rebecca. While you only need 2 of 3 parts to qualify for an E/M on an established patient, you need to know why the patient came in to be seen. This sets the foundation on which information is needed to support and build the correct level of service to bill.
Marie Lewis, CPC, CPC-H

[kte01a]

Since the chief complaint can be implied, can you infer the reason for the visit from the MDM?

[RebeccaWoodward*]

Implied? Not sure I understand how a CC can be implied. Can you elaborate?

CHIEF COMPLAINT (CC)
The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words.

DG: The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness. (These guidelines do not permit the CC to be pulled from the assessement and plan)