The Missing Chief Complaint

A common problem with provider documentation is the missing chief complaint (CC). CPT® defines the CC as “A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s words.”

The 1995 and 1997 Documentation Guidelines for Evaluation and Management (E/M) Services specifically require, “The medical record should clearly reflect the chief complaint.” Many electronic health records (EHRs) provide a field to enter a chief complaint or reason for the visit, but it is often inferred from the history of present illness (HPI). An easily identifiable chief complaint is the first step in establishing medical necessity for services rendered. If the patient record does not reflect a chief complaint, the service is either a preventive service, or is unbillable.

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 PCP, who manages the patient’s DM II and GERD. A Pulmonologists 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.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered 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, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered 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, and a member of the Asheville-Hendersonville AAPC Local Chapter.

5 Responses to “The Missing Chief Complaint”

  1. Jenny Harvey says:

    I often see the chief complaint as follows: “Patient here for follow-up”, or “Needs refills.” Is this a valid CC? As an auditor, I tend to disallow this unless the rest of the medical record demonstrates that the patient has an active issue that requires evaluation and/or treatment on the day of the visit.

    I would love to hear from the auditors out there. What are your thoughts on this? Is this a valid CC or not?

  2. Monica says:

    Personally, I don’t see this as a chief complaint. The patient should be promted to state what medications need refilled for what conditions as well as state the condition being followed uped.

  3. Janet says:

    Our EHR allows a CC, which states something like this: Skin lesion

    However, the description (painful, red, itchy, growing) is in the HPI. Is this adequate?

  4. Juddi Schneider, CPC, CPC-I, CPMA says:

    Who is the author of this article? I agree with what is written but would like to give credit where credit is due if I used this information as supporting documentation.

  5. Sherry J, CPMA, CIC, CEDC says:

    @Jenny H – No, “pt here for follow up” is not a valid chief complaint. Follow up care is not a diagnosis. The issue that is requiring the follow-up care is the true chief complaint for the given date of service. “Pt here for test results” is not valid either. The fact the patient is there for results is secondary to the underlying reason the tests were performed. The CC would also be the underlying condition the patient is presenting for a medication refill.

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