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Chief Complaint

  1. Default Chief Complaint
    Medical Coding Books
    We are having a discussion within my office about what can be the CC. The doctors think that using f/u is ok. I remember an auditing seminar that I went to, the speaker stated that "f/u" for CC is not good enough and won't work. How would you work a CC if the pt is comming back for a 2 or 4 wk f/u?
    Stephanie, CPC, HCS-D

  2. #2
    North Carolina
    Our MAC frowns on this type of documentation...(Quote)

    "Indicate clearly the chief complaint and/or reason for the visit. Don't limit the chief complaint to "follow-up" without identifying the problem(s) being followed."

    What is the patient following up for (elevated BP, DM, sprained foot, etc) "2 week f/u for ***" is typically what I recommend.
    Last edited by RebeccaWoodward*; 04-30-2010 at 08:23 AM.

  3. Default
    Thanks, that's what I was thinking but I needed backup to get my providers to understand. What if they put f/u from 3/16/10 appt. Would that be appropriate?
    Stephanie, CPC, HCS-D

  4. Default CC
    "The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words".

  5. #5
    what if the chief complaint is follow up. I have been told to look at the assessment for what the pt is following up on. I don't agree and argue that while it may be redundant, it's necessary to state in the CC what the conditions are and then again in the assessment, along with the status and plan.
    adrianne, cpc

  6. #6
    Milwaukee WI
    Default Assessment is not necessarily complaint
    Let's say patient told to come in for follow-up of HTN.

    Let's say that in the course of the examination the physician discovers that patient has bradycardia.

    The bradycardia would certainly be part of the assessment, but it was NOT the chief complaint.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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