chief complaint question

AmandaW

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follow up visit for inpatient hospital stay or observation hospital stay.....

Is "doing better" or "doing ok" or "feeling fine" ok for chief complaint in this kind of setting? Dr. asked and that's what the patient says.
 

dyates

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Chief complaint is a description of the condition as described in the patients own words. Doing fine is "describing what? Chief complaint should be follow up to hospitalization for XYZ condition. Doing Fine is not a chief compliant

Diana
 

Jewel

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no chief complaint

if there is no chief complaint, is that uncodable or do you down code?
 

DeeCPC

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If all E/Ms billed require a chief complaint then what would you down code to?

The chief complaint explains the reason for the provider to see the patient. It is the medical necessity for the visit.

A lot of providers believe that the hospital is a running comentary on the visit-maybe clinically but not for coding and billing. Their note has to stand on its own.
 

AmandaW

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So if medically, the patient really IS sick and does need to be hospitialized but truly has NO complaints that day-not uncomfortable in any way, the physician at very least needs to document "Patient doing ok, f/u for pneumonia" or at least whatever the diagnosis is? Possibly JUST Pneumonia?
 

AmandaW

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What about Chief Complaint: Denies any complaints. Or denies any discomfort?
 
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Chief complaint

The chief complaint for a patient who is inpatient or in observation status is the reason for the hospitalization/observation ... for example, chest pain or SOB or pneumonia

"Feeling fine" or "Doing okay today" or "no complaints" is part of the interval history.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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