The Chief Complaint: A Vital Documentation Element

The Chief Complaint: A Vital Documentation Element

by Kerin Draak, CPC, CPC-I, CEMC, COBGC

The CPT® codebook defines the Chief Complaint (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.” CPT® recognizes five levels of presenting problems: Minimal, Self-limited or minor, Low severity, Moderate severity and High severity. The CC can be problem-oriented or preventative.

The CC is related to the Nature of the Presenting Problem or “disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter,” according to the CPT® manual. The definitions for the CC and the Presenting Problem overlap.

Centers for Medicare & Medicaid Services (CMS) E/M documentation guidelines define the CC similarly to CPT®, and further state, “The medical record should clearly reflect the chief complaint.” Thus, the CC is a documentation requirement, and it is the provider’s responsibility to verify the CC with the patient.

Do not confuse the CC with the HPI; they are separate elements. The CC is the reason for the patient visit. The HPI details the CC. Although the CC directs the line of questioning in the HPI and the Review of Systems (ROS), the extent of history obtained is based solely on the provider’s clinical judgment. The extent of history obtained and exam performed should not be more than is medically necessary to evaluate a patient.

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