Go Back   AAPC Medical Coding & Billing Forums > Medical Coding > E/M
Forum Rules FAQ Members List Calendar Search Today's Posts Mark Forums Read

Reply
 
Thread Tools
  #1  
Old 01-02-2009, 11:30 PM
LLovett LLovett is offline
True Blue
 
Join Date: Apr 2007
Posts: 1,643
LLovett is on a distinguished road
Question Necessity of the chief complaint

I am dealing with an outside coding consulting agency and their lead coder and myself are having several disagreements on interpretation of the 1997 guidelines.

The big one today, lol, is the chief complaint. Per the guidelines it states "A chief complaint is indicated at all levels" and does not include it in the chart used to determine level of history.

My interpretation is that you must always have a chief complaint in order to bill an E/M code since they do not take it into consideration with the 3 elements that deteremine the level of history which you don't have to use to level established visits.

Her take is

"The statement you are referring to is under 'Section A' titled documentation of history. I see where it says a CC is indicated at all levels, however this is is directly stated under the history section A. It has always been my interpretation (as well as that of the Institutional Compliance office at my previous position) that these are parts of each other and they do not warrant separating out the sentence you reference. "


And as hard as it is to imagine, I am dealing with many notes that have no chief complaint and no history documented at all. The physician is no longer working with us but we are still cleaning up the mess. I am telling them if it doesn't have a CC, we are not billing it.


I am hoping to get feedback on this either way and all opinions and supporting documentation is greatly appreciated.


Thanks,

Laura, CPC
Reply With Quote
  #2  
Old 01-03-2009, 12:21 AM
feliciathomas feliciathomas is offline
Networker
 
Join Date: Apr 2007
Location: Atlanta, GA
Posts: 59
feliciathomas is on a distinguished road
Thumbs up

Laura,

The 1997 guidelines clearly state that the medical record should cleary reflect the chief complaint, however, it may be included in the description of the history of the present illness.

If it is stated there - you should bill the visit.
__________________
Felicia A. Thomas, CPC
Atlanta, GA
Reply With Quote
  #3  
Old 01-03-2009, 02:47 AM
cdcpc cdcpc is offline
Networker
 
Join Date: Apr 2007
Posts: 89
cdcpc is on a distinguished road
Default

If the CC is stated within the history portion of the documentation, it can be used for the CC. I would not use the same statement for both the CC and a component of history (like ROS).
For instance, if the documenation states "patient is here for a runny nose" I would use runny nose as the CC, but I cannot use it for the ENT ROS.
This is just my two cents.
Good luck
__________________
Carrie, BS, CPC
Reply With Quote
  #4  
Old 01-05-2009, 06:47 PM
LLovett LLovett is offline
True Blue
 
Join Date: Apr 2007
Posts: 1,643
LLovett is on a distinguished road
Default

Thank you for your responses. I really appreciate hearing how other coders are interpreting the guidelines.

Unfortunately, I am not exaggerating when I say no history, no chief complaint.

Many times this part of the templated form is left completely blank.

Thanks again and Happy New Year!

Laura, CPC
Reply With Quote
  #5  
Old 01-09-2009, 12:28 AM
tauros0427 tauros0427 is offline
Contributor
 
Join Date: Apr 2007
Location: Chicopee, MA
Posts: 15
tauros0427 is on a distinguished road
Default

If these are returning patients the doctors don't have to document the history if they do document any exam and decision making (Assessment).

We were taught from a chart auditor that we could include the chief complaint as the location in the HPI. The Chief Complaint is often missing in our records as well.
__________________
Tarringo T Vaughan BA, CPC
Director of Pain Management
Billing Services
Reply With Quote
  #6  
Old 02-19-2009, 11:12 AM
HCCCoder HCCCoder is offline
Guru
 
Join Date: Apr 2007
Location: Woodland Hills, CA
Posts: 120
HCCCoder is on a distinguished road
Default

This is a really great point!
I too agree, that if there is no CC-Reason for the visit- then there is no E/M. Why is the patient seeing the doctor?

I am doing an audit right now and pt is an est. patient and there is no CC and no History documented.

I am not going to code any level of service for this date.

What are your toughts?

thank you in advance,
Lilit
__________________
CPC CCS
"The true way to render ourselves happy is to love our work and find in it our pleasure."
Reply With Quote
  #7  
Old 02-19-2009, 12:42 PM
ARCPC9491 ARCPC9491 is offline
True Blue
 
Join Date: Apr 2007
Posts: 701
ARCPC9491 is on a distinguished road
Default

You can still score out a level using the exam and medical decision making components. The chief complaint is a part of the history.

"To qualify for a given type of history all three elements in the table must be met. (A chief complaint is indicated at all levels)"

My take is all levels "of history".... which means if you're using the history to score out an E/M and you have no CC, then you have no E/M

Hope that helps

Last edited by ARCPC9491; 02-19-2009 at 12:45 PM.
Reply With Quote
  #8  
Old 02-19-2009, 01:12 PM
HCCCoder HCCCoder is offline
Guru
 
Join Date: Apr 2007
Location: Woodland Hills, CA
Posts: 120
HCCCoder is on a distinguished road
Default

Thanks for the replies.

My whole point is that, what is the reason for the visit? The DG states that the CC needs to be clearly documented on every record and I don't see any CC documented at all. If there is no reason for the visit, then there is no medical necessity for the E/M on given DOS.

Lilit
__________________
CPC CCS
"The true way to render ourselves happy is to love our work and find in it our pleasure."
Reply With Quote
  #9  
Old 02-19-2009, 01:58 PM
1073358 1073358 is offline
Expert
 
Join Date: Apr 2007
Posts: 435
1073358 is on a distinguished road
Default

Per WPS Medicare, on an est pt visit, all 3 of the components MUST be there in order to qualify as even the lowest level. In choosing your LOS, you only need to consider the 2 highest, but all 3 need to be there. If 3 are not there, Medicare says you must bill with a 99499 and submit documentation.
I agree that this is a pain and will cause alot of extra work, but that is what they are telling us on our lunchtime medicare EM conferences we participate in.
Reply With Quote
  #10  
Old 02-20-2009, 08:04 AM
HCCCoder HCCCoder is offline
Guru
 
Join Date: Apr 2007
Location: Woodland Hills, CA
Posts: 120
HCCCoder is on a distinguished road
Default

This is good 1073358!! Thank you! Great point!
Might you have any document to proof this?

Thank you,
Lilit
__________________
CPC CCS
"The true way to render ourselves happy is to love our work and find in it our pleasure."
Reply With Quote
Reply

Thread Tools

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off




Disclaimer: Although AAPC staff members will monitor these forums periodically, we cannot be responsible for the information posted herein, nor guarantee its accuracy. Our members may discuss various subjects related to medical coding, but none of the information should replace the independent judgment of a physician for any given health issue. Please note that the opinions expressed here do not necessarily reflect those of AAPC.

All times are GMT -6. The time now is 08:04 AM.

AAPC - Top

Powered by vBulletin® Version 3.8.1
Copyright ©2000 - 2014, Jelsoft Enterprises Ltd.
Copyright ©2014, AAPC