Wiki Auditing subsequent visits

[cjackson]

Medicare guidelines state " chief complaint is 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." DG : The record should clearly reflect the chief complaint."

Question:

Is cc required on subsequent visits for hospitalized patients if the physican is using the Physical Exam and the MDM to drive the charge?

 

[LLovett]

Per WPSMedicare, yes. If there is no chief complaint there is no reason for the visit and no medical necessity so it is not a billable service.

This is something we struggle with in my IM/FP inpatients. I keep harping on them that they have to give me a reason every day. It doesn't have to be extensive, F/U HTN, is fine. But it has to be there everyday. I agree it seems repetitive when the patients are in for weeks at a time but I can see why it is required.

Laura, CPC, CPMA, CEMC