AAPC - Back to school
Results 1 to 5 of 5

Thread: Chief Complaint and HPI

  1. #1

    Default Chief Complaint and HPI

    AAPC: Back to School
    If a note does not contain a Chief Complaint or an HPI on an established patient, but has a detailed exam and moderate MDM, is it billable since you only need two of the three compontents for an E/M level?

  2. #2
    Join Date
    Apr 2007
    North Carolina


    I wouldn't allow it. The DG's state...

    The documentation of each patient encounter should include:

    • reason for the encounter and relevant history, physical examination
    findings and prior diagnostic test results;

    !DG: The medical record should clearly reflect the chief complaint.

    Not providing the chief complaint creates an issue for medical necessity. It would be difficult to justify a detailed exam with moderate MDM (your example) with the absence of a CC. The CC paints a picture for the reason of the visit and illustrates the complexity.

  3. #3
    Join Date
    Apr 2007
    Newport News, VA


    I agree with Rebecca. While you only need 2 of 3 parts to qualify for an E/M on an established patient, you need to know why the patient came in to be seen. This sets the foundation on which information is needed to support and build the correct level of service to bill.
    Marie Lewis, CPC, CPC-H
    Last edited by Eagle Eye; 09-29-2010 at 10:34 AM. Reason: forgot to sign

  4. #4
    Join Date
    Apr 2007
    Greenville, SC


    Since the chief complaint can be implied, can you infer the reason for the visit from the MDM?

  5. #5
    Join Date
    Apr 2007
    North Carolina


    Implied? Not sure I understand how a CC can be implied. Can you elaborate?

    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.

    DG: The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness. (These guidelines do not permit the CC to be pulled from the assessement and plan)

Similar Threads

  1. Coding from HPI or Chief Complaint?
    By amarie234 in forum Medical Coding General Discussion
    Replies: 7
    Last Post: 01-27-2015, 12:10 PM
  2. chief complaint/HPI
    By cindyh in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 10-18-2012, 11:52 AM
  3. Chief Complaint & HPI
    By nperry in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 02-18-2011, 02:15 PM
  4. Chief Complaint & HPI
    By nperry in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 02-15-2011, 11:29 AM
  5. Chief Complaint and HPI
    By dballard2004 in forum E/M
    Replies: 7
    Last Post: 02-14-2011, 02:15 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.