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Wiki Chief Complaint question

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jlb102780

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Good Afternoon,

I have a question on documenting the Chief Complaint. We are a large Cardiology group. I have started to notice on some of the encounters that the CC is only being documented as "presents for Annual and Evaluation". Would this be considered a prevenative service? I'm asking because I came across an article posted on AAPC that said:

"If the patient doesn?t have a problem (for instance, she just needs an annual exam), there is no chief complaint. You must bill a preventive E/M service."

http://news.aapc.com/index.php/2013/03/8-tips-for-compliant-history-component-documentation/

Now most of our patients are well established with us, and with multiple cardiac conditions being addressed. I'm not sure if these would fall under a prevenative service, but with the CC only showing as "annual", I'm not too sure if a regular E/M is meeting guidelines as well.

Any thoughts??

Thanks,
 
Chief Complaint Question

If the patient is being seen for chronic active problems this physician has been treating, you may use the CC of: f/u of (list conditions).
That being said the physician must give status of each of the conditions he/she is seeing the patient for in their HPI.
 
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