Wiki CC

[skm510@live.com]

I am in the process of reviewing pt charts and I am noticing that 90% of the time our Dr's are not stating a CC they just start right in with a HPI. From everything I have read "ALL" E/M's must have a CC listed even if it's simply follow - up to xyz correct?

 

[Naveen Rachagolla]

Chief Complaint

Chief Complaint
A CC is a concise statement that describes the symptom, problem, condition, diagnosis,
or reason for the patient encounter. The CC is usually stated in the patient's own words.
For example, patient complains of upset stomach, aching joints, and fatigue. The
medical record should clearly reflect the CC.

https://www.cms.gov/Outreach-and-Ed.../downloads/eval_mgmt_serv_guide-ICN006764.pdf

 

[skm510@live.com]

OK, so here is an example of E/M's that are bothering me:

The office visit started at 1:30 and finished at 1:45. The patient is a 74-year-old female who was initially seen for bright red blood per rectum. She has undergone a banding of her internal hemorrhoids, as well as a screening colonoscopy which showed some diverticulosis and internal hemorrhoids, but no other abnormalities. She comes in today with minimal complaints. She states her high-fiber diet has been working well. Her stooling is much more comfortable, but she has not completely resolved her constipation. She has a noticeable difference if she has decreased her fiber intake with how much constipation she experiences. She is moving her bowels once a day. She denies any nausea, vomiting, or abdominal pain.


To me this note does not have a concise CC... Would this be acceptable in an audit? Thank you for your help!!

 

[Naveen Rachagolla]

The office visit started at 1:30 and finished at 1:45. The patient is a 74-year-old female who was initially seen for bright red blood per rectum. She has undergone a banding of her internal hemorrhoids, as well as a screening colonoscopy which showed some diverticulosis and internal hemorrhoids, but no other abnormalities. She comes in today with minimal complaints. She states her high-fiber diet has been working well. Her stooling is much more comfortable, but she has not completely resolved her constipation. She has a noticeable difference if she has decreased her fiber intake with how much constipation she experiences. She is moving her bowels once a day. She denies any nausea, vomiting, or abdominal pain.

As per my knowledge i would consider CC as Constipation with DX Code series 564.??, you can see the bolded text in the above para which makes her worry and leads to a visit.

 

[MikeEnos]

I agree with Naveen, but as a 'best practice' I would strongly advise your provider to clearly state the chief complaint. It should be clear if they are here to follow-up on their chronic condition, evaluation of an acute condition, or a preventative routine visit.