Question Palliative Care E/M

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Titusville, FL
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I am a new coder working in hospice/palliative care.
My question concerns the chief complaint.

If I do not see a chief complaint in the visit report is it considered
a preventive medicine E/M encounter?

I know this is the general rule concerning evaluation and management encounters, but I just wanted to
confirm this applies to palliative care and hospice as well.

I appreciate the help. Thanks!
 

thomas7331

True Blue
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I am a new coder working in hospice/palliative care.
My question concerns the chief complaint.

If I do not see a chief complaint in the visit report is it considered
a preventive medicine E/M encounter?
The chief complaint is just a brief statement of the reason for the visit. It doesn't have to be labeled as a chief complaint - it may be in the body of the note itself, such as in the HPI, and it does not need to be an actual 'complaint' - it may just be the condition or diagnosis which the provider needs to monitor or follow-up on.

Absence of a chief complaint does not necessarily mean that the visit is preventive, and in hospice/palliative care, providers would not be performing preventive services. If you cannot determine from the documentation the reason that the provider is seeing the patient, then you would need to query the provider for additional information. Hope that helps some.
 
Messages
6
Location
Titusville, FL
Best answers
0
The chief complaint is just a brief statement of the reason for the visit. It doesn't have to be labeled as a chief complaint - it may be in the body of the note itself, such as in the HPI, and it does not need to be an actual 'complaint' - it may just be the condition or diagnosis which the provider needs to monitor or follow-up on.

Absence of a chief complaint does not necessarily mean that the visit is preventive, and in hospice/palliative care, providers would not be performing preventive services. If you cannot determine from the documentation the reason that the provider is seeing the patient, then you would need to query the provider for additional information. Hope that helps some.
This does help. Thanks so much.
 
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