# Chief Complaint - Followup from Procedure



## rlmiller

I work for a GI group and have been seeing physicians use "Follow up from Procedure" as a Chief Complaint.  This is a true statement, the patient's do not have any signs or symptoms at time of service.  However it is a vague statment and wanted to make sure from an auditing stand point this would be ok for a Chief Complaint.

Thank you. Robin


----------



## MnTwins29

*No*

I would not accept that statement as a C/C.   What was the problem that required the procedure?   And is the visit during the global period of the surgery?


----------



## rlmiller

Our Endoscopy procedures do not have global days attached to them.  Would it be better to use the findings from the procedures as the CC for the follow up?


----------



## FTessaBartels

*Chief Complaint is NOT diagnosis*

The chief complaint is the problem/issue/reason for the visit ... as told BY THE PATIENT.
So "F/U from surgery" is certainly a valid chief complaint.

Certainly it would be *better* if the CC read:  "F/U from appendectomy"  or "F/U from upper GI endoscopy done mm/dd/yy."  I do NOT like to see simply "F/U"  .... but "F/U from surgery" is acceptable.


Hope that helps.

F Tessa Bartels, CPC, CEMC


----------



## MnTwins29

*Hate to nitpick with an expert...*

but we have been told by auditors that "F/U from surgery" was not sufficient.   Agree with you about a diagnosis not needed - maybe what would be better is what type of surgery (i.e. F/U knee arthroscopy)?  The audito did not provide what he was looking for, but stated this was insufficient.   I understand that thinking, but your reply is now making me wonder....


----------



## AprilSueMadison

Along this same line...

we have patients who come in for skin cancer screenings where there may not be anything specific they have noticed.  Our notes tend to say "Patient here for general exam" for the CC.  I do not think this is specific enough.  What do you all think?  What can we do differently?


----------



## AprilSueMadison

This was posted awhile ago, but I'm still looking for some sort of status on my last post.  Any ideas?


----------



## bridgettemartin

I realize this is an older post, but I also am wondering if there is any new guidance regarding this scenario?



rlmiller said:


> I work for a GI group and have been seeing physicians use "Follow up from Procedure" as a Chief Complaint.  This is a true statement, the patient's do not have any signs or symptoms at time of service.  However it is a vague statment and wanted to make sure from an auditing stand point this would be ok for a Chief Complaint.
> 
> Thank you. Robin


----------



## mitchellde

There is absolutely nothing wrong with a CC of F/U from procedure or surgery.The original post did not specify who the auditor was and who they worked for. If I came across an auditor that stated this was incorrect I would challenge that ruling.  There is no need to know what surgery the patient is here following up on or what the condition was that required surgery because you are not going to code those conditions.  If the patient is presenting for a F/U encounter unless complications are noted then the patient is doing well and has no issues.  The only dx code you need to assign is a F/U code (V67.-) or a surgical aftercare code depending on what the provider does.  If it is a surveillance only then it is a F/U if there is hands on mgt then it is aftercare such as dressing changes or suture removal.


----------



## jennileeo

*F/U as a chief complaint*

Hi,
A CC of "Follow-up" should never be used. "Many patients come into the office for follow-up care, but follow-up care is not a diagnosis" - National Alliance of Medical Auditing Specialists' Reference Guide 2013 and 2014 edition. The fact that the patient presents to the office for a follow-up to a surgery is secondary to the underlying reason the surgery was performed. The true chief complaint would the be gallstones (e.g.) the doctor performed the surgery for.  

Jennilee


----------



## mitchellde

jennileeo said:


> Hi,
> A CC of "Follow-up" should never be used. "Many patients come into the office for follow-up care, but follow-up care is not a diagnosis" - National Alliance of Medical Auditing Specialists' Reference Guide 2013 and 2014 edition. The fact that the patient presents to the office for a follow-up to a surgery is secondary to the underlying reason the surgery was performed. The true chief complaint would the be gallstones (e.g.) the doctor performed the surgery for.
> Jennilee


This is incorrect, you never use a dx code for a condition that is no longer present.  You are coding the patient's condition at this point in time, I absolutely know that the provider does not document the presence of gallstones at the followup encounter and therefore it cannot be coded.
The coding guidelines tell us to use aftercare V codes or follow up V codes for the post operative encounters.  Follow up is a diagnosis, there is a code for follow up in the International Classification of Diseases.  You NEVER code the preoperative condition for the postoperative encounters.


----------



## Robyn07

Robin, 

I would not accept a general statement like that, however, it could be made better by including the procedure being followed up on.  Also, the provider may want to include any problems or the lack of problems if known at the time of the appt. 

Robyn M. Alvarado, CPC


----------

