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No chief complaint

  1. #1
    Default No chief complaint
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    I am new to Auditing E/M. My question is: What happens if there is no Chief complaint documented. The physician states F/U for ________. Patient has no complaints. Can we still code this document?

  2. #2
    Columbia, MO
    If it is a new patient then you have no visit level. The guidelines state that if no Cheif comlaint is listed then history is not reviewed and cannot be counted. Youn can however still have ab established level.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Your note indicates that the physician states this is follow-up which seems to indicate this is an established patient. What is the patient being followed up for?

  4. #4
    The only E/M service that can be coded without a chief complaint is well care.

    It looks like maybe the transcription people didn't understand what your provider said. I would take it back and ask for the note to be amended with the correct information.

    You don't have to count the level of history towards your E/M level on an established patient but you always have to have a chief complaint.

    Laura, CPC

  5. #5
    Quote Originally Posted by Jessheartz View Post
    I am new to Auditing E/M. My question is: What happens if there is no Chief complaint documented. The physician states F/U for ________. Patient has no complaints. Can we still code this document?
    Is that how the physician wrote it ? F/U for ________. Or did you not fill in the blank for us , i think i might be misunderstanding. But if the physician did not write anything then i would agree maybe who transcibed did not understand what he wrote or said so they left it blank, which in my opinion is wrong, they should have flagged this back as incomplete for him to dictate. But if he did write HTN or DM then yes that can be used as a CC for an est patient. I like to refer back to E/M university case of the week.

  6. #6
    Even though this is a couple days old, I'd like to put my comment in as well.
    There are a couple of scenes I can picture that have already been described, e.g., the not understanding by a transcriptionist and replacing the term with a line (____________________). In that setting they usually refer back to the provider for clarification and update the note before finalizing.
    One thing that is also unfortunately not uncommon is that a provider dictates (or writes) "patient seen in follow-up." (period, end of sentence). If I see that and the rest of the note doesn't indicate what the follow-up is for, well then I do not allow this because there just isn't a chief complaint.
    I use this as a trainings opportunity to inform the provider that there needs to be more for it to count.
    Karolina, CPC, CPMA, CEMC

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