Question Chief complaint documentation

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Per the 95 and 97 guidelines a chief complaint is required for all categories of e/m, correct? No matter what type of visit, a cc is required to establish medical necessity for that particular day, right? Each note must stand alone? I'm getting push back from the education and compliance departments where I work and based on my research and the guidelines, is it or is it not correct to identify a cc for each subsequent hospital visit? Thank you in advance
 

thomas7331

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The CC is required, however it doesn't have to be labeled specifically as a 'chief complaint' in the note and doesn't even have to be an actual 'complaint'. As per the guidelines, it can be any "symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter."
 
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Costa Mesa, CA
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The CC is required, however it doesn't have to be labeled specifically as a 'chief complaint' in the note and doesn't even have to be an actual 'complaint'. As per the guidelines, it can be any "symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter."
Thank you for your reply. Another thing that is being said by the education and compliance department is that the CC will come from the H&P or the consult...auditors will not reference that for a subsequent visit audit, correct? 99231-99233?
 

thomas7331

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Thank you for your reply. Another thing that is being said by the education and compliance department is that the CC will come from the H&P or the consult...auditors will not reference that for a subsequent visit audit, correct? 99231-99233?
Well, in theory, notes should stand on its own and be clear as to why the provider is seeing the patient. But for inpatient services, providers are working from a complete record of the stay and it may be putting an undue burden to require them to restate information from other parts of a record every time. I think most auditors and payers these days understand this and aren't going to start penalizing organizations for minor details or imperfections as long as the documentation as a whole reflects an accurate record of the care given. In an ideal world every note would be perfect, but at some point, each organization has to balance the quality of documentation with the administrative costs of imposing more rules and administrative burdens on their physicians. Remember that guidelines are just that - they're meant to be a guide to how to document, not a rule that has to be followed absolutely strictly to the letter at all times. Some judgment is always involved.
 
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