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chief complaint missing?

  1. #1
    Location
    Springfield, Mo
    Posts
    388
    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
    Location
    Kansas City, MO
    Posts
    433
    Default
    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
    Location
    Ellenville, New York
    Posts
    1,177
    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.

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