Wiki Auditing Subsequent Care Visits

[kdean]

How do people audit subsequent care codes, when an interval history is required? We have been told that a chief complaint for subsequent care code could be stated in the body of the note. Does it have to be stated in the history portion of the note or can it be anywhere in the note? Also, what if the chief complaint is not easily inferred, could or would an auditor go back to the H & P because it is a shared inpatient record? Also, how does an interval history play into this scenario, does an interval history need a chief complaint to be restated everyday?


I am concerned the audit requirements put the physicians at a disadvantage because we are telling them to document the history (interval) one way but holding them accountable another way by restating a cheif complaint each time when an interval history focuses on the period of time since the doc last performed an assessment. I really need some clarification on the interval history.

 

[Karolina]

Each visit needs to have a chief complaint, but it can be anywhere in the note. There has to be a reason why your provider sees the patient and each note. The chief complaint for a daily visit could differ from the chief complaint at admission, for example if complications developed. Some providers mention the chief complaint in the A/P part of the note.