Wiki Necessity of the chief complaint


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I am dealing with an outside coding consulting agency and their lead coder and myself are having several disagreements on interpretation of the 1997 guidelines.

The big one today, lol, is the chief complaint. Per the guidelines it states "A chief complaint is indicated at all levels" and does not include it in the chart used to determine level of history.

My interpretation is that you must always have a chief complaint in order to bill an E/M code since they do not take it into consideration with the 3 elements that deteremine the level of history which you don't have to use to level established visits.

Her take is

"The statement you are referring to is under 'Section A' titled documentation of history. I see where it says a CC is indicated at all levels, however this is is directly stated under the history section A. It has always been my interpretation (as well as that of the Institutional Compliance office at my previous position) that these are parts of each other and they do not warrant separating out the sentence you reference. "

And as hard as it is to imagine, I am dealing with many notes that have no chief complaint and no history documented at all. The physician is no longer working with us but we are still cleaning up the mess. I am telling them if it doesn't have a CC, we are not billing it.

I am hoping to get feedback on this either way and all opinions and supporting documentation is greatly appreciated.


Laura, CPC

The 1997 guidelines clearly state that the medical record should cleary reflect the chief complaint, however, it may be included in the description of the history of the present illness.

If it is stated there - you should bill the visit.:)
If the CC is stated within the history portion of the documentation, it can be used for the CC. I would not use the same statement for both the CC and a component of history (like ROS).
For instance, if the documenation states "patient is here for a runny nose" I would use runny nose as the CC, but I cannot use it for the ENT ROS.
This is just my two cents.
Good luck :)
Thank you for your responses. I really appreciate hearing how other coders are interpreting the guidelines.

Unfortunately, I am not exaggerating when I say no history, no chief complaint.

Many times this part of the templated form is left completely blank. :(

Thanks again and Happy New Year!

Laura, CPC
If these are returning patients the doctors don't have to document the history if they do document any exam and decision making (Assessment).

We were taught from a chart auditor that we could include the chief complaint as the location in the HPI. The Chief Complaint is often missing in our records as well.
This is a really great point!
I too agree, that if there is no CC-Reason for the visit- then there is no E/M. Why is the patient seeing the doctor?

I am doing an audit right now and pt is an est. patient and there is no CC and no History documented.

I am not going to code any level of service for this date.

What are your toughts?

thank you in advance,
You can still score out a level using the exam and medical decision making components. The chief complaint is a part of the history.

"To qualify for a given type of history all three elements in the table must be met. (A chief complaint is indicated at all levels)"

My take is all levels "of history".... which means if you're using the history to score out an E/M and you have no CC, then you have no E/M

Hope that helps
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Thanks for the replies.

My whole point is that, what is the reason for the visit? The DG states that the CC needs to be clearly documented on every record and I don't see any CC documented at all. If there is no reason for the visit, then there is no medical necessity for the E/M on given DOS.

Per WPS Medicare, on an est pt visit, all 3 of the components MUST be there in order to qualify as even the lowest level. In choosing your LOS, you only need to consider the 2 highest, but all 3 need to be there. If 3 are not there, Medicare says you must bill with a 99499 and submit documentation.
I agree that this is a pain and will cause alot of extra work, but that is what they are telling us on our lunchtime medicare EM conferences we participate in.
Unfortunately, all I have is a power point on this and the part pertaining to what I said was a verbal thing from her. I have it wrote down, but its not in print from WPS. It may be if you dig for it, but I do not have time to do so now.

I would suggest if you are with WPS Medicare, that you could email the eFaq line and they could maybe provide you something in writing on this.
Need an opinion

Please code this if you can. Isn't the CC and HPI the same thing? Was is the difference between the two?

Subjective: The patient is brought in by his mother concerned about the possibility of skin cancer. There is a family hx of nonmelanoma skin cancer. The patient has had frequent sunburns in the past. The patient has no specific concern's at today's visit. The remainder of the past, family and social history, current medications and allergies and a comprehensive review of 14 systems are noted on the blue form inside the clinical record.

Objective: Skin examination of the head, neck, chest, back, arms and legs was conducted. There is tan to light brown pigmented well-defined macules scattered in the sun exposed areas.

A/P: 1. Screening examination for malignant neoplasm of the skin. No malignant or premalignant lesions were appreciated at today's visit.
2. Lentgoes (self limiting diagnosis) The patient was reassured as to the the benign nature of this condition and the use of sunscreens was reinenforced.

In my opinion, I would code this as a new patient 99202 reason is the HPI with only 1 element (location: skin)

What is your opinion, please help!

CC is the Chief Complaint, the reason for the visit. And the HPI is the history of present illness, those are 2 separate things.

EPF Phys exam (1997 DG)

99202 is correct

Per CPT guidelines EVERY level of history requires a chief complaint.

When auditing our physicians we give them credit the first time we find it omitted and educate them on the necessity.

The second time it is an unbillable service. <--this usually corrects the issue.
I agree w/ Lilit. You code to the CC, meaning this sets the medical necessity for your exam. How do you even know what is necessary to examine w/out it. To me, this is a direct corrolation w/ the MDM. You can always do a complete exam on everyone you see but what makes it necessary to do that w/out the cc. It's a good learning tool for the other doctors on what NOT to do.