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.
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