Wiki Chief complaint and HPI

[tknotts@ptchc.com]

I was doing a chart audit on a patients chart. I came across this chart.
CC-check up, review labs
HPI- pt is 91 yrs old, To update records as has blood drawn here per PCP in MD when visiting daughter who resides in this area. Was last seen in this clinic in 7/2016. A recent medial exam by another provider since last office visit PCP 4/2019.
No recent hospital or emergency department visit since last office visit.

I told the provider in the chart review that there is no CC or HPI so this claim is unbillable. He says there is a CC and HPI, but how can I count either? It doesn't tell me anything.
Tell me what you all think of this.

 

[Pam Warren]

I think that this is not billable. Why were the labs drawn? What did the lab results show? If you can't determine a symptom or condition based on documentation, there's no way to support medical necessity for an office visit. Just because they state "CC" or "HPI" doesn't mean the criteria are met.

 

[Pathos]

Per CMS E/M guidelines:

Chief Complaint (CC)
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.



As you have stated, an E/M must have a chief complaint. What defines a proper chief complaint can be up for debate, however as CMS E/M guidelines state, the CC is a statement that describes the reason for the encounter. I would take the next step and agree with Pam that simply stating "Follow up", "Annual wellness", "Med check" or another vague statement is not very solid and I would doubt the chance of the chart passing an audit. Another CC suggestion might be "Follow up on [chronic condition] and review associated labs together". I haven't seen a lot of push back from CMS regarding Chief Complaints, however it's definitely a risk to take from a provider point of view.

Also, a lot of practices have their ancillary staff write out the Chief Complaint. Perhaps installing a proper process on what the patient is truly in the office for is not just good business practice, but woudl definitely help shield your practice against a future audit.

I would be cautious to bill the note as you have described in your example. You might get "lucky" and the note will fly under the radar, or the note gets audited and denied. Worse still, if the provider habitually does their CC in this manner, audits will catch this practice sooner or later.

Hope this is helpful!