Wiki No chief complaint on global visit

[kjstearns]

One of our docs performed an appendectomy on a patient and saw the patient the next day in the hospital. His dictation looked like this:

Abdomen soft, non-tender
wound looks good
continue I/V antibiotics

I know that this is a global visit so there will be no charge, but does it still require a chief complaint?? I know CMS says that a chief complaint is indicated at all levels, but does this include global visits?

Thanks in advance,
Kirsten, CPC

 

[FTessaBartels]

Surgery Post-op Visit

It doesn't really make any difference, because you aren't going to code it anyway.

BUT ...

We train our surgeons to title their routine post-op visits as: Surgery post-op (or FU) visit

(This helps our coders, too, so they know which notes to "ignore" when abstracting a chart.)

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[kjstearns]

Thank you, that does help. We are trying to get our docs in that habit as well. Unfortunately, we're getting a lot of grief about it! I guess that's the nature of what we do

Thanks again,
Kirsten, CPC