Chief Complaint

March 17th, 2015 - Codapedia Editor
Categories:   Audits/Auditing   Coding  
0 Votes - Sign in to vote or comment.

The guidelines go on to read, "The medical record should clearly reflect the chief complaint." This leaves physicians to ask the question, does the chief complaint need to be listed separately from the history of the present illness or the rest of the rest of the history?

The guidelines also say:

!DG: The CC, ROS and PFSH may be listed as separate elements of history, or theymay be included in the description of the history of the present illness.

That is, a physician or other health care professional who is billing for evaluation and management services, may include the reason for the visit, or the chief complaint, within the history of the present illness. Sometimes the chief complaint is very specific. "Patient reports that they have a four-week history of abdominal pain." Sometimes the reason for the visit may be less specific such as, "The patient is here for follow-up of their chronic medical problem." That is permitted as long as the remainder of the history of the present illness describes the problem that the patient has presented to the physician.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Chronic Pain Coding Today & in the Future
July 19th, 2021 - Wyn Staheli, Director of Research
Properly documenting and coding chronic pain can be challenging. As is commonly the case with many conditions, over the years, there has been a shift in the identification of different types of pain, including chronic pain. Understanding where we are now and where we are going will help your organization prepare for the future by changing documentation patterns now.
How Does Global and Professional Direct Contracting (GPDC) Affect Risk Adjustment?
July 15th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
CMS recently announced the 53 Direct Contracting Entities (DCEs) that will be participating in the April 1, 2021 through December 31, 2021 Global and Professional Direct Contracting (GPDC) Model. Among those participating is Clover Health Partners, who runs an in-home primary care program that has the potential to help Medicare ...
How to Properly Assign ICD-10-CM Codes for Pain
July 14th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Pain is a common diagnosis among all specialties so it should not be surprising to find there are 162 ICD-10-CM codes for reporting it and over 80 mentions in the ICD-10-CM Official Guidelines for Coding and Reporting which describe when certain types of pain should be reported and how the codes should be sequenced.
Will CMS Allow Medicare Advantage Organizations to Risk Adjust from Audio-Only Encounters? 
July 13th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
While audio-only telehealth services became a covered benefit during the PHE, CMS put limitations on using the data from those encounters for risk adjustment scoring. Medicare Advantage (MA) plans cannot use the information from these encounters to be scored for risk adjustment; however, it can be used for risk adjustment scoring of ACA plans.
Compliance in the Dental Office or Small Practice
June 29th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
If your practice does not already have a compliance program in place, you will want to get started after reading this article. We have uncovered some important findings with the Office of Inspector General (OIG) in dental practices you need to be aware of. A compliance program offers standard procedures to follow, ...
Important Changes to Shared/Split Services
June 16th, 2021 - Aimee Wilcox CPMA, CCS-P, CST, MA, MT and Wyn Staheli, Director of Content Research
Reporting of split (or shared) services has always been wrought with the potential for incorrect reporting when the fundamental principles of the service are not understood. A recent CMS publication about these services further complicates the matter.
Understanding Non-face-to-face Prolonged Services (99358-99359) in 2021
June 3rd, 2021 - Aimee Wilcox CPMA, CCS-P, CST, MA, MT and Wyn Staheli, Director of Content Research
Due to the extensive changes in office or other outpatient services (99202-99215), there are many questions which still need to be answered, one of which is related to the prolonged services without face-to-face contact. This article explores the question regarding the appropriate use of codes 99358/99359 and how to report it.



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association