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Necessity of the chief complaint

  1. #1
    Question Necessity of the chief complaint
    Medical Coding Books
    I am dealing with an outside coding consulting agency and their lead coder and myself are having several disagreements on interpretation of the 1997 guidelines.

    The big one today, lol, is the chief complaint. Per the guidelines it states "A chief complaint is indicated at all levels" and does not include it in the chart used to determine level of history.

    My interpretation is that you must always have a chief complaint in order to bill an E/M code since they do not take it into consideration with the 3 elements that deteremine the level of history which you don't have to use to level established visits.

    Her take is

    "The statement you are referring to is under 'Section A' titled documentation of history. I see where it says a CC is indicated at all levels, however this is is directly stated under the history section A. It has always been my interpretation (as well as that of the Institutional Compliance office at my previous position) that these are parts of each other and they do not warrant separating out the sentence you reference. "

    And as hard as it is to imagine, I am dealing with many notes that have no chief complaint and no history documented at all. The physician is no longer working with us but we are still cleaning up the mess. I am telling them if it doesn't have a CC, we are not billing it.

    I am hoping to get feedback on this either way and all opinions and supporting documentation is greatly appreciated.


    Laura, CPC

  2. #2
    Thumbs up

    The 1997 guidelines clearly state that the medical record should cleary reflect the chief complaint, however, it may be included in the description of the history of the present illness.

    If it is stated there - you should bill the visit.
    Felicia A. Thomas, CPC
    Atlanta, GA

  3. #3
    If the CC is stated within the history portion of the documentation, it can be used for the CC. I would not use the same statement for both the CC and a component of history (like ROS).
    For instance, if the documenation states "patient is here for a runny nose" I would use runny nose as the CC, but I cannot use it for the ENT ROS.
    This is just my two cents.
    Good luck
    Carrie, BS, CPC

  4. #4
    Thank you for your responses. I really appreciate hearing how other coders are interpreting the guidelines.

    Unfortunately, I am not exaggerating when I say no history, no chief complaint.

    Many times this part of the templated form is left completely blank.

    Thanks again and Happy New Year!

    Laura, CPC

  5. #5
    Chicopee, MA
    If these are returning patients the doctors don't have to document the history if they do document any exam and decision making (Assessment).

    We were taught from a chart auditor that we could include the chief complaint as the location in the HPI. The Chief Complaint is often missing in our records as well.
    Tarringo T Vaughan BA, CPC
    Director of Pain Management
    Billing Services

  6. #6
    Woodland Hills, CA
    This is a really great point!
    I too agree, that if there is no CC-Reason for the visit- then there is no E/M. Why is the patient seeing the doctor?

    I am doing an audit right now and pt is an est. patient and there is no CC and no History documented.

    I am not going to code any level of service for this date.

    What are your toughts?

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

  7. #7
    You can still score out a level using the exam and medical decision making components. The chief complaint is a part of the history.

    "To qualify for a given type of history all three elements in the table must be met. (A chief complaint is indicated at all levels)"

    My take is all levels "of history".... which means if you're using the history to score out an E/M and you have no CC, then you have no E/M

    Hope that helps
    Last edited by ARCPC9491; 02-19-2009 at 12:45 PM.

  8. #8
    Woodland Hills, CA
    Thanks for the replies.

    My whole point is that, what is the reason for the visit? The DG states that the CC needs to be clearly documented on every record and I don't see any CC documented at all. If there is no reason for the visit, then there is no medical necessity for the E/M on given DOS.

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

  9. #9
    Per WPS Medicare, on an est pt visit, all 3 of the components MUST be there in order to qualify as even the lowest level. In choosing your LOS, you only need to consider the 2 highest, but all 3 need to be there. If 3 are not there, Medicare says you must bill with a 99499 and submit documentation.
    I agree that this is a pain and will cause alot of extra work, but that is what they are telling us on our lunchtime medicare EM conferences we participate in.

  10. #10
    Woodland Hills, CA
    This is good 1073358!! Thank you! Great point!
    Might you have any document to proof this?

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

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