Results 1 to 3 of 3

chief complaint missing?

  1. #1
    Springfield, Mo
    Default chief complaint missing?
    Medical Coding Books
    On an established patient visit, if I am not counting the history toward the level, only the exam and MDM... does there have to be a chief complaint documented?
    Here is a typical HPI for one of my doctors:
    SUBJECTIVE: This 63-year-old male notes approximately 50% improvement compared to last visit of 04/19/11. He grades pain +2/10. He states the injection was helpful for a few days. Symptoms returned but then he did start to get somewhat better once again about 3 days ago. He states the strapping to the longitudinal medial arch did not help a great deal.

    I'm saying "improvement in WHAT"? Do I need to have a talk with him about CC? Or are we OK without it?
    solocoder CPC

  2. #2
    Kansas City, MO
    Time to have a talk with your doctor. There needs to be a chief complaint...."the medical record should clearly reflect the chief complaint" per CMS' documentation guidelines.
    The CC can also be documented by the nurse who is rooming the patient.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC, AAPC Fellow
    PMCC Licensed Instructor
    2018 Chapter President, Kansas City, MO

  3. #3
    Ellenville, New York
    Default Doesn't have to be a separate section
    There still might be a CC documented in that note - if later in the note the condition that is "improved" by other means, such as a new treatment plan for the condition that is "improved", then a CC could be obtained from the record. A CC does not have to be a separate part of the history in order to be "clearly" documented. Yes, that portion of the note certainly doesn't have that, but if you can glean the CC after reviewing the entire note, that is acceptable.

Similar Threads

  1. Replies: 7
    Last Post: 06-01-2018, 10:21 PM
  2. Chief Complaint - I have a auditing question
    By Coder07 in forum Auditing General Discussion
    Replies: 3
    Last Post: 09-22-2011, 01:45 PM
  3. Chief Complaint
    By AZ_coder in forum E/M
    Replies: 2
    Last Post: 07-17-2011, 02:12 PM
  4. No chief complaint
    By Jessheartz in forum E/M
    Replies: 5
    Last Post: 07-29-2009, 12:16 PM
  5. No Chief Complaint
    By opiecpc in forum Diagnosis Coding
    Replies: 3
    Last Post: 07-14-2009, 12:43 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.