Documented Chief Complaint Is a Must

One common problem with provider documentation is a missing chief complaint (CC). Unless the visit is for a preventive medicine service, the lack of a CC means that the service will be deemed medically unnecessary (and unpayable) by any insurer.
Often, providers begin their subsequent notes with symptoms the patient may not have, or a comment pertaining to the patient’s status in relation to a procedure or medication, but without mentioning why the patient is being treated. This shortcoming is especially pressing when multiple providers of different specialties treat the same patient. For example, if an admitting physician and one or two consulting providers all bill subsequent inpatient care using the same principal diagnosis, only the provider who gets his claim to the payer first will be paid. The others most likely will be denied as duplicate services.
Multiple treating providers should bill services with the principle diagnosis of their specialty. For example, a patient is admitted with an acute myocardial infarction, a history of diabetes mellitus type II, chronic obstructive pulmonary disease, and gastro esophageal reflux disease, with a cardiologist as the physician of record. The patient also is followed by the primary care physician (PCP), who manages the patient’s DM II and GERD. A pulmonologist manages the COPD.
In this case, the admitting cardiologist would bill using the AMI as the principal diagnosis. On subsequent visits, the cardiologist would continue to code the AMI as principal diagnosis (along with any newly-diagnosed cardiac illness), the PCP would continue to code the DM II and GERD, and pulmonary would continue to code the COPD.
Providers must carve out the patient treatment pie according to their specialty. This can become tricky, especially when hospitalists are involved in treating the patient, or when the PCP is still involved and has not yet relinquished care of the patient.

Evaluation and Management – CEMC

John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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