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chief complaint-considered as a CC?

  1. #1
    Default chief complaint-considered as a CC?
    Medical Coding Books
    is "here for f/u", "f/u routine", "s/p hysterectomy" considered as a CC? imo, "follow up" is a weak cc. but, apparently some consider it as a legitimate cc. thoughts? please provide source when applicable. thank you.
    CCS, CPC

  2. Default
    Follow up routiene is a rarely occuring CC, with very low morbidity level;
    S/P hysterectomy is not CC.

  3. #3
    Default Trailblazer
    Here's the Trailblazer recommendation for cc:

    1. Indicate clearly the chief complaint and/or reason for the visit.

    Do not limit the chief complaint to “follow-up” without identifying the problem(s) being followed.

    By this, the reason for the visit could be "follow up s/p hysterectomy". I'd say follow up for sure, though, to indicate that it's a postoperative check. If it's within the global period, ie a no charge visit, then I don't think the documentation lingo matters as much since it's not supporting an E/M.
    Belinda S. Frisch, CPC, CEMC
    Author of "Correct Coding for Medicare, Compliance, and Reimbursement"

  4. #4
    thanks for the responses. i will present this to my coworkers.
    CCS, CPC

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