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Auditing subsequent visits

  1. Default Auditing subsequent visits
    Medical Coding Books
    Medicare guidelines state " chief complaint is a concise statement describing the symptom, problem condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient's words." DG : The record should clearly reflect the chief complaint."


    Is cc required on subsequent visits for hospitalized patients if the physican is using the Physical Exam and the MDM to drive the charge?

  2. #2
    Per WPSMedicare, yes. If there is no chief complaint there is no reason for the visit and no medical necessity so it is not a billable service.

    This is something we struggle with in my IM/FP inpatients. I keep harping on them that they have to give me a reason every day. It doesn't have to be extensive, F/U HTN, is fine. But it has to be there everyday. I agree it seems repetitive when the patients are in for weeks at a time but I can see why it is required.

    Laura, CPC, CPMA, CEMC

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