Wiki Chief Complaint - Can anyone tell me

[dyoungberg]

Can anyone tell me if a Chief Complaint is needed on in-office procedure documentation? Our provider does RF Ablation of veins in office. It is the only thing done and billed for that day.

Thanks very much
Debbie, CPC

 

[CatchTheWind]

No, chief complaint is only needed for E/M.

 

[mitchellde]

While a chief complaint per se is not needed, you do need a diagnosis that supports the medical necessity for the procedure, and this must be documented in the procedure note, it cannot be obtained from previous notes.

 

[dyoungberg]

While a chief complaint per se is not needed, you do need a diagnosis that supports the medical necessity for the procedure, and this must be documented in the procedure note, it cannot be obtained from previous notes.

Thank you both for the information. It's confirms what I was thinking.