Pulmonology Coding Alert

Chief complaint need not be at the very top of the note, but the physician must state it clearly. Getting dinged on audits because you don't have a chief complaint listed at the top of your physician's documentation? Don't give up until you check the entire note. Although you'll benefit from a chief complaint documented clearly at the beginning of the note, Medicare doesn't require that you list it at the top. "The chief complaint should be clearly illustrated," says Suzan Berman (Hvizdash), CPC, CEMC, CEDC, senior manager of coding and compliance in the departments of surgery and anesthesiology at the University of Pittsburgh Medical Center. "Listing it amongst the assessment might not paint the clearest picture. There might be other issues that came out in the visit (or other conditions the clinician is concerned about as they relate to the chief complaint or the possible treatment options), but they [...]