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Documentation of Chief Complaint

  1. #11
    Milwaukee WI
    Default Definition of chief complaint
    Medical Coding Books
    I find it interesting as well that the carriers get more and more specific about what they expect the physician to document ...

    Especially when the definition of a chief complaint is the problem that brings the patient to the physician, "usually stated in the patient's words" (source: CPT 2009 professional edition, E/M services guidelines, page 1).

    In other words, the patient is here because his leg hurts, not because he has a fractured tibia.

    Oh well ...

    We are covered by WPS Medicare and we DO ask the physicians to document chief complaint themselves. If they don't we have to take it from the first sentence of the HPI (so they don't get any HPI credit for that - no double dipping). A few audits with their E/M levels being lowered is usually pretty effective in getting them to document the CC themselves.

    F Tessa Bartels, CPC, CEMC

  2. #12
    Default Noridian called me back
    Well, interesting info today.

    Ashley from Noridian called me back. The before mentioned article was written by a lady on their education staff. She based her article on the MLN articles about 95 and 97 guidelines, not on something stating chief complaint must be done by the provider.

    Noridian told me even though it doesn't say anything about who can document the CC in the MLN documents, that is where this idea came from.

    They gave me a phone number and name to a medical director that approves these articles. I tried to call him and the line is currently being checked for trouble.

    As I learn more I will post it.

    Laura, CPC

  3. #13
    Duluth, Minnesota
    seems a bit overkill at this point. I mean really, since the provider does the HPI why wouldn't they ALSO be stating the CC? Are they going to do a complete HPI without ever mentioning the CC? (the reason the patient is even there in the first place)... doesn't make sense to me. The HPI and CC are "one in the same area" of the HISTORY component. Along with the ROS and PFSH that make up the HISTORY Element, and with the other ELEMENTS of the service (EXAM/MDM) the level is finally determined.

    I don't get why it's such an issue - why there has to be something in stone. Do your providers want the ancillary staff to document the CC? I mean, is it THAT much of a bother to them that they can't or won't state the CC in their dictation?

    what am i missing?

    I feel it's pretty basic, straight forward and should go without saying that the CC is done right along with the HPI which is done by the provider. I also agree with Tessa & Rebecca and their posts.
    More so, I still can't figure out this would (or should) be an issue.
    Last edited by dmaec; 04-21-2009 at 01:15 PM. Reason: forgot to add Rebecca - i agree with her too ;)
    Donna, CPC, CPC-H

  4. #14
    Apparently you have providers that document much better than a lot of mine do.

    Good example, nurse documents "1 week recheck ears"

    provider does the hpi "doing better, finished meds"

    Based on needing a chief complaint to bill any E/M service, if the cc is invalidated b/c the nurse wrote it, I can't bill for this service at all.

    I have over 500 providers that could be affected by any changes I advise, Yes I need something in writing from CMS or at this time WPS.

    I am sorry if this posts bothers anyone, I will keep any future information I obtain to myself.

    Wishing you all the best,

    Laura, CPC

  5. #15
    Duluth, Minnesota
    I was simply stating my opinion Laura - the post's haven't upset me (I'm sorry if mine upset you). Feel free to offer your info and opinion to all - that's what this is for, the "Forum thing" ... to help out others, to ask questions, to post responses, opinions, help, guidelines, etc....

    sorry my opinion and inability to understand why this should be such an issue at your facilty has upset you. But don't take the fact that my post upset you out on all others.. I'm sure they're waiting for more info when you find it, and even I am anxious to see if you come up with anything written in stone. (or whether it even has to be!)

    I would have to believe that of your 500 providers, the majority of them follow the documentation guidelines and document the CC right along the HPI and info from the ROS/PFSH(regardless of who obtains that), along with the EXAM and MDM. I'm having real difficulty believing that a provider would see a patient, document the HPI, ROS, EXAM and MDM and fail to mention the CC. Even the stuff ancillary does is dictated in the note or should be, right?
    Donna, CPC, CPC-H

  6. #16
    Lansing, Michigan
    I have to agree with Laura. I have some providers who simply state 3 month recheck and states their chronic diagnoses. I am trying to get better documentation but some of them are simply stuck in their ways. I also would like some real documentation that states that the physician (or PA) must document the HPI and CC. I know this doesn't exactly make sense to Donna but when docs try to simply cut time and try to pass off as much as they can to their MA. Laura, if you come up with any documentation let me know. You can send me a private message if you'd like. Thanks. kathy

  7. #17
    I am still waiting for a response from an emailed question, the ph# they gave me has now been disconnected. As of right now the only thing I can find from WPSMedicare supports that the only part of the history that has to be documented by the physician is the HPI. Which is how I have always understood it to be.

    Donna, I don't know where you are located but it is apparently not in southeastern Ohio or Mid Michigan, trust me the majority are not following guidelines. It is really scary what is going on and no wonder the OIG is cracking down. I personally have been charged level 5 consults by 3 different specialists (cardiology, gastro, and gen surgery) and the only people that ever saw me were residents, I didn't even get the pleasure of meeting the doctors that the services were billed under, much less actually receiving the service they billed for. Thankfully none of them were my providers but I have no doubt this is very common, in this area at least, because these providers were all from different offices. This was in Feb of this year. The same thing happened at a completely different facility in Jan of this year when my daughter was in the hospital. I know that is a bit off topic but I just wanted to illustrate the type of environment I came into back in September 2008, these type of things were seen as ok when I came in. Obviously they are not and I am doing my best to change that but when "everyone else does it that way" you have to support the things you want them to change.

    Laura, CPC

  8. #18
    Default Finally got a response from WPSMedicare
    "As you probably know, the Centers for Medicare & Medicaid Services (CMS) does not specify who may record the chief complaint (CC) component of an evaluation and management (E/M) service in either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services. Although CMS has clarified that only the physician or non-physician practitioner performing the E/M service may document the history of present illness (HPI) element of the exam, WPS Medicare does not interpret this to mean that the ancillary staff may not question the patient about their chief complaint. WPS Medicare will permit ancillary staff to record the CC; however, the physician/NPP must validate the CC in his or her documentation.

    WPS Medicare recently published an article containing questions and answers pertaining to the history component of E/M services. Question one in the list of questions and answers specifically addresses ancillary staff recording the patient's chief complaint. You may wish to review this article on our Website at the following address: "

    This is the response I got back from WPS today. According to this as long as the physicians documentation supports the cc it is ok for ancillary staff to obtain it.

    Laura, CPC

  9. #19
    Kansas City, MO
    Thumbs up
    I have been following this post and I think it is a perfect example of the "mud" we deal with everyday. Thank you all for the information you have provided from the different carriers, it provides a clear picture of how important it is to know what your specific carrier rules are.

    My group is now part of the J5 MAC that was awarded to WPS and we have been struggling trying to get answers to several questions related to E/M's for the past year. We formed an E/M Workgroup of coding and compliance managers, consultants and instructors all of which are CPC's and several of them are members of the WPS POE-AG. When WPS finally published their E/M Q&A - History, we were very happy to see that they had answered almost all of our questions.

    From my own personal experience, we do have an issue with CC. We get patients that tell the nurse one thing and then when the physician gets in the room, it is something different. At this point, the providers have been very receptive and are trying to alter their routine and restate the CC as the first line of their documentation.
    Angela Jordan, CPC, COBGC, AAPC Fellow
    Senior Managing Consultant
    Medical Revenue Solutions, LLC
    AAPC National Advisory Board - Southwest
    AAPCCA BOD Chair 2012-2013

  10. #20
    Thank you so much for listing these source documents. I have been on the hunt for something substantial enough that I could deliver to our EMR vendor and multiple providers.
    This is an industry standard that has been hard to "prove" to other entities due to the "lack" of specificity in the 1995/97 guidelines. Apparently it allows some individuals enough room to argue that because it does not specifically state "ancillary staff can't document the HPI" - means that they can defend that position in court.
    I believe this issue needs direct attention - exponentially so now with EMR becoming so relevant.
    Thank you again, cheers!

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