# Chief Complaint - I have a couple questions



## tfischer

I have a couple questions..

1.) I know Medicare requires a chief complaint on every note, or they consider it non-billable. Can I use the chief complaint toward my HPI elements? For example: 
*
CC: Chest Pain

Patient experiences symptoms for 3 days and onset began while chopping wood. *

Can I use the Chest Pain for my Location in the HPI, or can I only count that as the documenting of the chief complaint?


2.) I educate my physicians to only review the systems that are pertinent to the problem the patient is coming in the office for. I tell them they can get credit if they mention that all others are reviewed and negative. One physician will state a couple review of systems in the HPI, and then state below in his documentation "Negative with the exception of the above."  Is this an acceptable phrase?

Thank you!


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## LLovett

You can not use your chief complaint like that, it would be double dipping. Also the HPI has to be done by the provider, anyone can get the chief complaint. In your example though it wouldn't make a difference as you would not have 4 elements of HPI even including location.

To get credit for a comphrensive ROS, they have to actually do it first off, but they need to use a statement like "*All* other systems reviewed and negative except for HPI" or just "All other systems reviewed and negative". Without stating all we have no idea what other systems were done and negative.

Laura, CPC, CPMA, CEMC


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## RebeccaWoodward*

katmryn78 said:


> You can not use your chief complaint like that, it would be double dipping. Also the HPI has to be done by the provider, anyone can get the chief complaint. In your example though it wouldn't make a difference as you would not have 4 elements of HPI even including location.
> 
> To get credit for a comphrensive ROS, they have to actually do it first off, but they need to use a statement like "*All* other systems reviewed and negative except for HPI" or just "All other systems reviewed and negative". Without stating all we have no idea what other systems were done and negative.
> 
> Laura, CPC, CPMA, CEMC



Just a moment...

"Anyone can get the chief complaint"...

The CC is considered part of the HPI and as we know, the HPI can not be delegated to ancillary staff.  

*Who can perform and document the chief complaint? *

Per the Documentation Guidelines, the chief complaint is required for all levels of history and must be clearly reflected in the medical record. Ancillary staff cannot perform and document a chief complaint (CC). The CC is part of the HPI, which must be performed by the physician

http://www.wisconsinmedicalsociety.org/education/faq#q16

*Q*- Where does it state that ancillary staff can record the chief complaint (CC)? In addition, can you confirm that ancillary staff can obtain the review of systems (ROS) and past, family and social history (PFSH?) 

*A*- The 1995 and 1997 Documentation Guidelines (DG) do not address who can record the chief complaint. WPS Medicare will allow the CC when recorded by ancillary staff. *However,* the physician must *validate the CC in the documentation*. The 1995 and the 1997 Documentation guidelines indicate ancillary staff may obtain the ROS and PFSH but they do not indicate the ancillary staff can obtain the History of Present illness. 

http://www.wpsmedicare.com/part_b/education/evalmngmntqahistory.shtml


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## LLovett

*Agree to disagree...*

Obviously I disagree with that. I know there have been several posts back and forth on this issue. The chief complaint is listed as a separate element of history in both the 95 and 97 guidelines, not part of the HPI. The only element of history that must be obtained by the provider, per the guidelines, is the HPI. 

The WPS link is great because it supports that. Yes the HPI needs to support the chief complaint, that only makes sense. Validate does not mean restate or reobtain.

I have asked several published sources of this statement where they got the info that the chief complaint must be obtained by the provider, as yet no one has provided me anything other than their own personal opinion of the guidelines. The ones that stated they got it from CMS told me they were either misquoted or they had spoken in error because CMS has never made that statement. Some carriers have but not CMS and obviously not WPSMedicare

So ultimately this comes down to the carrier level. 

Laura, CPC, CPMA, CEMC


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## RebeccaWoodward*

I don't agree with your concept but that's ok.  The coding world is not a universal residence of absolute....


"The issue has been clarified several times with Cathleen Scally at CMS and she has verified that HPI must be done by the billing provider. There was a past discussion about a possible misquote of Dr. McCann in a 1998 article that indicated that he said it was acceptable for someone else to document the HPI as long as the physician reviews/adds to it.   

The quote in question was forwarded to Ms Scally who then wrote to Dr. McCann to determine whether or not he had been misquoted in the publication, pointing out that CMS has never permitted anyone but the physician/NPP who is performing the E/M to do the HPI.   She also noted that in certain circumstances like an ER where a triage *nurse* *takes the initial chief complaint *and perhaps even an HPI *it is required **that the physician/NPP of record must actually review the chief complaint and HPI with the patient and write it him/herself and not just sign what an ancillary employee may have recorded*. 

Dr. McCann's response to Ms. Scally was clear and unequivocal:

"Kit, I totally concur with your interpretation. What kind of doctor doesn’t take his/her own history?""

http://www.codapedia.com/~article_118_Who can document the HPI_.cfm

Personally, I'm following the guidance of Cathleen Scally----- *Cathleen M. (Kit) Scally M.S., CNM, Division of Practitioner Services, CMS* Cathleen.Scally@cms.hhs.gov


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## SCanterbury

The guidelines don't specifically mention which parts of the visit must be performed by the billing provider (physician or NPP). Instead, CMS has indicated that the work described in the guidelines should be understood as physician (or NPP) work except when specific allowance is made otherwise.

Specific allowance is made for individuals other than the billing provider to obtain and document the ROS and PFSH subcomponents of History. In the '97 guidelines, allowance is made for ancillary staff to obtain and document the vitals (with virtually all Medicare carriers allowing this when '95 guidelines are used as well).

This is mentioned in the 10/24/05 Part B News, where it says:

_"The entire set of guidelines were written to identify the *physician work *[emphasis added] necessary to perform and document" the medical record for an E/M service, an E/M guru from CMS tells Part B News. The official says those are - as Buechner points out - ROS, PFSH and vitals._​
So by omission of any specific allowance, the CC and HPI subcomponents of History should be understood to represent physician/NPP work. That said, Kit Scally has made comments that indicate they would be willing to allow the CC to be documented by ancillary staff.

Per the Wisconsin Medical Society’s website (no longer appears):

_5.Question: Where does it state that the physician must obtain and document the chief complaint and history of present illness?

ANSWER: For HPI (history of present illness) see WPS Part B Medicare FAQ site, under documentation. For the chief complaint (CC), it was necessary to email Cathleen (Kit) Scally, at CMS for her opinion. The answer basically states that ancillary staff may document the CC. Following is a quote from her response:

"I guess a purist would say the CC is in the realm of the physician or qualified NPP performing the E/M but in reality ancillary employees such as a triage nurse or office medical assistant will write down the presenting problem/condition why the patient is being seen. Also, in reality while an employee might write down the CC the physician or qualified NPP will generally ask the patient again why he/she is there. Saying this, I believe the CC can be asked and documented by an ancillary employee. But if the ancillary employee does not capture the CC it should certainly be asked and documented by the physician._​
BUT, at the MAC level, many auditors still apply the "if no specific allowance was made in the guidelines for ancillary staff to take the CC then it must be done by the physician" rule. Kit Scally has retired, and the comments posted above are no longer accessible on the web. So in my opinion the safe course to follow for both the CC and HPI is to operate with the understanding that they must be obtained and documented by the provider.

As to whether HPI information that happens to be included with the CC can be used, there is nothing in the guidelines that says you cannot use HPI information because the doctor happened to include it in the CC field. Where does it make that restriction in the guidelines? In other words, I would credit...

CC: 2 day hx of severe stabbing pain in lower right leg

...the same as...

CC: Pain

HPI: 
Duration--2 days
Location--lower right leg
Quality--stabbing
Severity--severe

This is not a double-dipping matter because nothing is being used twice. The chief complaint credited is just a version stripped of the details that will be credited properly as HPI info. Sometimes providers give lots of good information on the CC line, while others write the specific details in a separate HPI section. It doesn't matter. I've only known of one Medicare carrier that tried to say otherwise, and as far as I know, they reversed that decision.

Seth Canterbury, CPC, ACS-EM


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## RebeccaWoodward*

_"BUT, at the MAC level, many auditors still apply the "if no specific allowance was made in the guidelines for ancillary staff to take the CC then it must be done by the physician" rule. Kit Scally has retired, and the comments posted above are no longer accessible on the web. So in my opinion the safe course to follow for both the CC and HPI is to operate with the understanding that they must be obtained and documented by the provider."_

Thank you, Seth. I truly appreciate your opinion~


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## LLovett

My carrier is WPS and they have clearly stated anyone can document the CC it does not have to be the provider. 

So depending on who takes the CC would depend on how you could use it. In your scenario in one of my offices the CC would be taken and documented by the nurse/MA and therefore could not be used towards any elements of HPI.

Having said all that I will let you know that according to the medical review department at WPSMedicare "headache" is a ROS for ENT and "dull ache" is severity not quality. When I asked for something to back this up, they flatly refused saying they don't publish their audit tools.They frustrate me to no end.


Laura, CPC, CPMA, CEMC


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## Walker22

I have just read the 1997 guidelines, and I am coming down on the side of the physician being required to document the CC, not the ancillary staff.


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## karenmeade

I have a doctor that states CC as regular check up....any advice on this one.


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## SHobbs

When the ancillary staff record the chief complaint should it be documented this information was obtained by the nurse?

One of our providers do not want to make the Chief Complaint "busy" by adding this information.


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