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No chief complaint on global visit

  1. #1
    Location
    Seattle First Hill
    Posts
    126
    Default No chief complaint on global visit
    Medical Coding Books
    One of our docs performed an appendectomy on a patient and saw the patient the next day in the hospital. His dictation looked like this:

    Abdomen soft, non-tender
    wound looks good
    continue I/V antibiotics

    I know that this is a global visit so there will be no charge, but does it still require a chief complaint?? I know CMS says that a chief complaint is indicated at all levels, but does this include global visits?

    Thanks in advance,
    Kirsten, CPC

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Surgery Post-op Visit
    It doesn't really make any difference, because you aren't going to code it anyway.

    BUT ...

    We train our surgeons to title their routine post-op visits as: Surgery post-op (or FU) visit

    (This helps our coders, too, so they know which notes to "ignore" when abstracting a chart.)

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Location
    Seattle First Hill
    Posts
    126
    Default
    Thank you, that does help. We are trying to get our docs in that habit as well. Unfortunately, we're getting a lot of grief about it! I guess that's the nature of what we do

    Thanks again,
    Kirsten, CPC

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