Need help - today if possible!
I have a physician that does not provide much info in his chief complaint. Typically he will only write things like "Barretts and polyps" or "hepatitis." I have explained that the chief complaint should be a statement, such as "I appreciate being asked to see Mr Smith in consultation for hepatitis."
Have any of you had to explain documentation guidelines for the chief complaint to one of your physicians? Did you reference any written guidelines? I am looking for some sources that contain a brief description of what should be included in the chief complaint. (Or if you are able to provide me with a simple, concise description in your own words, I would be very grateful.) I am hoping that by putting this description in other words, than my own, I will be able to convince my physician of the need for more information in the chief complaint.
CHIEF COMPLAINT (CC)
The CC is a concise statement describing the symptom, problem, condition,
diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words.
!DG: The medical record should clearly reflect the chief complaint.
This is from the 97 guidelines.
I have had issues with CC from several of my providers, so I feel your pain. On the bright side if they get a good HPI you can pull CC out of there as well.
This is from the Physicians guide to Medicare:
Evaluation and Management Background
Medicare pays physicians based on diagnostic and procedure codes that are
derived from medical documentation. E/M documentation is the pathway that
translates a physicianâ€™s patient care work into the claims and reimbursement
mechanism. This pathwayâ€™s accuracy is critical in:
â€¢ Ensuring that physicians are paid correctly for their work;
â€¢ Supporting the correct E/M code level; and
â€¢ Providing the validation required for medical review.
E/M includes some or all of the following elements:
â€¢ Documenting history. Each type of history includes some or all of the
o Chief complaint, which is:
- A concise statement that describes the symptom, problem,
condition, diagnosis, or reason for the patient encounter
- Usually stated in the patientâ€™s own words
Maybe this will get him to give you a little bit more.
Thank you Wendy and Laura!
I am getting ready to do battle!
I was also wondering....Would this meet the guidelines?
The physician only states "rectal bleeding" as the chief complaint, but then indicates in the HPI "referred for consultation by Dr Smith for an opinion and treatment of rectal bleeding."
Don't confuse the chief complaint with the HPI.
The Chief Complaint can be documented by ancillary staff. Typically the medical assistant documents the chief complaint when she takes the patient to the examine room. She/he may document vital signs and ask the patient why are you here today. That is why guidelines state the chief complaint is usually in the patients word.
The HPI can only be documented by the physician, and is a description of the development of the patients present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are Location, quality, severity, duration, timing, context, modifying factors, and Assoc signs and symptoms.
I beleive you are asking about where the physician should document a request for his opinion when billing a consult? Typically it is found in the History element of the E/M code. When I audit I am not really particular to where the physician documents the requests. I am just happy to see that it is documented.