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Necessity of the chief complaint

  1. Default
    Medical Coding Books
    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.

  2. #12
    Woodland Hills, CA
    Ok, great, not a problem.
    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  3. Question 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!


  4. #14
    Woodland Hills, CA
    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 Hx,
    EPF Phys exam (1997 DG)
    Low MDM

    99202 is correct

    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  5. Default Thanks!
    Thank you Lilit Martirosyan, CPC CCS for answering my question! That was very helpful!


  6. #16
    Woodland Hills, CA
    You are most welcome!
    "The true way to render ourselves happy is to love our work and find in it our pleasure."

  7. #17
    South Bend
    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.

  8. Default
    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.
    adrianne, cpc

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