Wiki Question about Chief Complaint

[LuckyLily]

How would you handle this coding situation for the CC and parts of HPI?

This is what the physician documented,

History of Present Illness:
1. Follow up, review apt
(name here) is doing well generally--summary of his issues are below.


I don't feel this states a Chief Complaint and there are no elements for the HPI. I don't think I should query the provider asking for the chief complaint and HPI because this can create a different e/m level after the physician has already signed the note and I think this encroaches on leading the provider. In the assessment/plan the physician does state what they went over.

Would you determine this as non-billable? Looking for advice on what you would do. Thank you

 

[thomas7331]

I would allow this. The guidelines only state that the medical record should reflect the chief complete and that it should be a "concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter." If the physician has stated that this is a follow up for the issues listed in the summary below, and that summary accurately documents those issues that required the follow up, then I believe that the note would meet the requirements.

It is not the best way to document a chief complaint and a feedback to the provider for documentation improvement may be a good idea if this is an ongoing problem, but I would not penalize the provider by making a service non-billable just because a minor issue such as this if the note otherwise supports a medically necessary E&M service..