There SHOULD be a CC, and the E/M guidelines say so. But, it can be taken from the HPI, and doesnt have to be seperately documented under a "CC" heading...Some docs like to throw their CC/HPI/ROS all into one big blob of a paragraph. You can pick apart, just not use twice.
In the CPT book, under the heading of "Instructions for Selecting a Level of E/M Service", it has "chief complaint" listed first under the description of each level of history. (I have an Expert CPT, but I think these guidelines are in reg CPT book).
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