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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