AAPC - Back to school
Results 1 to 4 of 4

Thread: Chief Complaint - I have a auditing question

  1. #1

    Default Chief Complaint - I have a auditing question

    AAPC: Back to School
    I have a auditing question regarding the chief complaint.

    Now I was wondering if it is possible to use the information in the chief compaint as part of your HPI and/or ROS?

    For instance CC: patient has fever, vomiting, headache and body aches.
    Now I know you cannot double dip so if you just use, for instance, fever as your CC can you use the rest of the CC in your HPI and/or ROS?

  2. #2
    Join Date
    Apr 2007


    The chief complaint should be a separate statement. If you pull the chief complaint out of the HPI, you cannot use that particular verbage for any HPI elements.

  3. #3


    The chief complaint is subjective patient data. The ROS and EXAM is objective data from the provider. Good luck!

    Simone, CPC

  4. #4
    Join Date
    Apr 2007
    Northwest Ohio

    Default ROS is subjective information

    I have to disagree, the ROS is subjective data that the patient is complaining of. The elements do fall under a SOAP format:
    O= Exam
    A= MDM (# of dx)
    P= Complexity of data and Risk

    I would use that information like you said, if you need it.

    When I teach (students or physicians) I always use this example:
    Patient comes in for fever, in speaking with the patient they state that they have been coughing really bad too, so bad they can barely function, yet the patient has been in the office for all this time and explaining their situation and has not coughed once. This would fall under the resp. system for the ROS.

    Objective findings is what the physician would find upon exam. Actual findings!

    Does that make sense?
    Mandy Flagg, CPC, CEMC
    Compliance Auditor

Similar Threads

  1. Chief Complaint
    By hthomson in forum Auditing General Discussion
    Replies: 8
    Last Post: 11-05-2013, 11:21 AM
  2. Chief Complaint
    By pscott in forum E/M
    Replies: 3
    Last Post: 06-26-2013, 04:28 PM
  3. Chief Complaint - With an E/M code
    By daguilar@swgiassoc.com in forum Gastroenterology
    Replies: 0
    Last Post: 03-28-2013, 02:15 PM
  4. Chief Complaint
    By AZ_coder in forum E/M
    Replies: 2
    Last Post: 07-17-2011, 02:12 PM
  5. No chief complaint
    By opiecpc in forum Diagnosis Coding
    Replies: 2
    Last Post: 11-17-2009, 11:49 AM

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.