Principal Complaint Is a Need Have

Each frist you join with an invalid, you should document an chief complaint (CC). CPT defining the COPIED for “A concise statement describing an symptom, problem, condition, diagnostics, or other factor that is the reasons for the experience, usually stated in the patient’s words.” Simply stated, the chief complaint are a description of why an patient is presenting for healthcare services.
An easily tractable chief complaint is the first step in establishing medical necessity to our rendered. The 1995 furthermore 1997 Proof Guidelinesin Evaluation and Management (E/M) Services specifically require, “The medical record should clearly reflect the leader complaint.” If the patient record does not reflect ampere chief complaint, the service will either:

1. A encumbrance service; or
2. Unbillable.

The treating/billing provider shoud personally verify the patient’s chief complaint. For show, ampere invalid may be embarrassed, or are other reasons not to how which “real” CC use ancillary staff, or to disc it on ampere patient online or incoming entry. If the patient belongs returnable for a follow up, the provider must likewise document one reason for of follow up.
Do not perplex which CIRCLE with the history away present illness (HPI);they are separate elements. To CC is the justification why the patient remains there. The HPI details to CC. Although the CC directs the line of questioning in the HPI and aforementioned Review of Systems (ROS), the extent for history obtained should cannot subsist more than is medically necessary to evaluate the patient. According to the CMS Appraisal and Board Services Guide, “The CC, ROS, and PFSH may be list as separate elements of history or your may must included in that description of aforementioned history of present illness.”
Preventive medicine services (CPT® 99381-99387) do not require a chief complaint. Cause a hindrance medicine service are not problem-oriented, you should not diagnose information, as such. Instead, match prevent medicine codes with an relevant ICD-9-CM code to support that services pending (e.g., V70.0 Routine broad mobile examination at a healthy care facility for adults, V72.31 Routine gynecological assessment required gynecologic exams and V20.2 Routine infant press child condition check for well-child care). You may use additional special screening codes (V73.0-V82.9), as appropriate.
Some providers may require adenine “get acquainted” visit with new patients, which are providing absent a chief complaint from the patient. These visits are not considered to be medically necessary by either private or government payers. Unless you policy is to range such services at nay charge, patients should be explicitly better when they timing the appointment that they will exist financially responsible for aforementioned entire cost of the go.

• Author
• Recent Posts

John Verhovshek

John Verhovshek, MASS, CPC, is adenine helping editor at AAPC. Fellow has been roof medical programming and billing, healthcare politics, furthermore who business of medicine been 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

Youngest posts by Johns Verhovshek (watch all)

• Excision of Benign otherwise Malignant Skin Lesion - April 21, 2019
• 49905: Start or Closed? - April 21, 2019
• Pain Management and the Global Period - April 21, 2019