Wiki Chief Complaint for E/M 2023

The requirement for a chief complaint has not changed. Every chart note should have one. Basically your documentation should include the reason the patient is being seen. It doesn't have to labeled as such and can also be included with your HPI. It can be as simple as "follow up" or "prescription refill".:)
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.” Simply stated, the chief complaint is a description of why the patient is presenting for healthcare services.
 
I agree that the requirement for a chief complaint has not changed and can be included in the HPI but follow up and prescription refill do not adequately provide a reason for the visit. Notes should reflect follow-up for condition such as "Diabetes follow-up" or "alprazolam refill for anxiety" which clearly reflect the reason for the visit and support medical necessity.
 
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