Chief Complaint - Does anyone know

[soprano]

Does anyone know if the CC can be documented by ancillary staff or does it need to be documented by the physician? If so, where can I find this in writing to show my physician? I can't find this in the 95 or 97 DGs.

 

[rthames052006]

Does anyone know if the CC can be documented by ancillary staff or does it need to be documented by the physician? If so, where can I find this in writing to show my physician? I can't find this in the 95 or 97 DGs.

I was just viewing the 95 DG's and here is what it does say-

"DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others"


That is the only thing I was able to find when I just skimmed it!

 

[soprano]

I saw that too but I am specifically looking for something regarding the CC. One of my NPs argued with me that a CC is not required for an E/M LOS. I want to show her somehwere it says that a valid CC is required for every LOS and who can document the CC.

 

[rthames052006]

I saw that too but I am specifically looking for something regarding the CC. One of my NPs argued with me that a CC is not required for an E/M LOS. I want to show her somehwere it says that a valid CC is required for every LOS and who can document the CC.

You may want to default to contacting your carriers to see what they say because I highly doubt you'll find anything that states who can document the cc, but what I take from what I saw that they are telling you what items can be documented by ancillary staff, since the cc is not listed I'd say only the provider can.

Regarding the cc the guidelines do state that it can be documentated separately or it can be included in HPI.

 

[Lassal423]

Along these same lines, what do you do when there is NO CC or HPI documented? Is that visit invalid?

I know the guidelines state there must be a CC, but if one is not documented, will the visit be valid?

Lora

 

[LLovett]

CC is always required for E/M

http://www.wpsmedicare.com/part_b/resources/provider_types/evalmngmnt.shtml

This link is to WPS Medicare E/M page. They have a lot of good info. As far as who can document it may depend on the carrier. WPS says anyone can but the provider must support it with their documentation. Other carriers may not accept this.

http://www.wpsmedicare.com/part_b/resources/provider_types/evalmngmntqahistory.shtml

Q 1. Where does it state that ancillary staff can record the chief complaint (CC)? In addition, can you confirm that ancillary staff can obtain the review of systems (ROS) and past, family and social history (PFSH?)
A 1. The 1995 and 1997 Documentation Guidelines (DG) do not address who can record the chief complaint. WPS Medicare will allow the CC when recorded by ancillary staff. However, the physician must validate the CC in the documentation. The 1995 and the 1997 Documentation guidelines indicate ancillary staff may obtain the ROS and PFSH but they do not indicate the ancillary staff can obtain the History of Present illness.

Q 8. Is chief complaint required for interval history in a nursing home?
A 8. The chief complaint is the reason for the visit. Documentation for all E/M must include the chief complaint.



Hope this helps,

Laura, CPC, CPMA, CEMC

 

[ollielooya]

Thanks, Laura, this information was helpful, as we've just added this particular Medicare Contractor to our service list. Good info to know!

 

[RebeccaWoodward*]

I saw that too but I am specifically looking for something regarding the CC. One of my NPs argued with me that a CC is not required for an E/M LOS. I want to show her somehwere it says that a valid CC is required for every LOS and who can document the CC.

My carrier states a CC is required for very LOS. I'll keep looking for aroung for the author; although I know it requires the provider.

Jurisdiction 11 Part B
E/M Weekly Tip: Chief Complaint

A chief complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return or other factor that is the reason for the patient encounter. A CC is required for all levels of service. The extent of the information gathered for the CC and history component is dependent upon clinical judgment and the nature of the presenting problem. The documentation must clearly reflect the CC.

Read the article below to learn more.

J1 Part B - History: Documentation
http://www.palmettogba.com/palmetto...Center~Weekly Tips~8UYH6H3481?open&navmenu=||

 

[RebeccaWoodward*]

Jurisdiction 11 Part B

What specific information can ancillary staff (e.g., RN, LPN, CNA) document during an evaluation and management (E/M) encounter? Can ancillary staff act as a scribe for a provider?

Answer:
Ancillary staff may only document:

Review of systems (ROS)
Past, family and social history (PFSH)
Vital signs

These three areas must be reviewed by the physician or non-physician practitioner (NPP) who must write a statement that it is reviewed and correct or add to it.

Only the physician or NPP that is conducting the E/M service can perform the history of present illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff. In certain instances, an office or emergency room triage nurse may document pertinent information regarding the chief complaint (CC)/HPI, but this information should be treated as preliminary information. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail.

http://www.palmettogba.com/palmetto...Asked Questions~EM~8EELQE6434?open&navmenu=||

 

[MnTwins29]

Forgive my cynicism...

but I love it when government guidelines state "in certain circumstances" but are vague. So it gives them latitude if our "certain circumstances" don't jive with THEIR "certain circumstances."

 

[RebeccaWoodward*]

but I love it when government guidelines state "in certain circumstances" but are vague. So it gives them latitude if our "certain circumstances" don't jive with THEIR "certain circumstances."

Touché....