Documentation of Chief Complaint

mrahn

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Hubbard, IA
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I can not seem to find any information as to who is to document the Chief complaint for family practice/internal med. I need this information in reliable source to show the nurse staff and the physician. There has been some bickering back and forth between the clinic supervisor and the coder. I think that it should be the nurse staff when they document the vitals, but the clinic supervisor disagrees and thinks that it should be the provider.

Any information and reliable source would be greatly appreciated

Thanks

M. Rahn, CPC
 

nomerz

Networker
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Wheat Ridge, CO
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I'm hoping someone can find some reliable sources for you because I was not, however, it has always been my understanding that the CC rolls into the HPI - the three main components of the history portion being HPI, ROS, and PMSH - and therefore should be documented by the provider.
 

m.j.kummer

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Local Chapter Officer
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Ashland, MO
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Check with your Medicare Administrative Contractor. WPS GHA requires the physician to document it. Palmetto GBA states “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.”

Most will allow ancillary staff to ask and document the reason for the encounter. (technically the chief complaint) "I have a sore throat". The physician/provider would then take the history ... when did it start, what have you done, have you had a fever, etc.

It would be nice if there was a clear cut answer, but it is payer specific.
 
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