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Satisfying cc

REGINALD068

Networker
Messages
66
Location
Monmouth County
Best answers
0
Good morning
Can someone please tell me if symptoms of a complaint counts towards meeting the required number of elements of any level? Ex: patient complains of low back pain, and neck pain. There is weakness, numbness and tingling in the upper right extremity. The pain worsens with ADLs and routine range of motion. The mid/low back pain is constant with radiation of pain down the left lower extremity. There is mild weakness, spasms and numbness/tingling noted in the lower extremity. The patient reports difficulty with ADLs and sleeping secondary to pain. Would you count weakness, numbness and tingling as elements towards a CC?

Thanks,
 

Pathos

Expert
Messages
403
Location
Beaverton OR
Best answers
0
Hello,

CMS E/M guidelines explains:

"While documentation of the CC is required for all levels, the extent of information gathered for the remaining elements related to a patient’s history depends on clinical judgment and the nature of the presenting problem.

Chief Complaint (CC)
A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words. For example, patient complains of upset stomach, aching joints, and fatigue. The medical record should clearly reflect the CC."

This makes me think that the Chief Complaint could easily be a symptom of a complaint, and any of the examples you've shared could count towards the CC.

Hope that helps!
 

REGINALD068

Networker
Messages
66
Location
Monmouth County
Best answers
0
I am back questioning this. For a 99214 level visit, it requires 4 CC/HPI. Would that be 4 separate CC with the HPI for each, or is it a combination?
 
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