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Thread: chief complaint

  1. #1

    Default chief complaint

    AAPC: Back to School
    I have been auditing an endocrinologist and for all of his established patients the chief complaint reads "Here for follow up evaluation. Endocrinologic." Is this satisfactory, or does he or his staff need to mention diabestes, thryoid, etc.? Please let me know what you think. Thanks in advance.

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default Sufficient

    It's sufficient - but not optimal.

    The chief complaint, technically, is what the PATIENT would say he is there for. "Follow-up" would about cover that.

    However, in an ideal world, the physician would use this to give the coder/auditor some clue as to the reason for the visit. "follow-up for DM2" or "Post-op follow-up" are two VERY different reasons for a follow-up appointment.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3


    Thank you for your help.

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