# chief complaint-Does there have



## AmandaW (Oct 3, 2012)

Does there have to be a chief complaint documented for subsequent
hospital visits?  (99231-99233)  (99224-99226)


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## LLovett (Oct 3, 2012)

*Yes, every visit must have a cc*

http://www.wpsmedicare.com/j8macpartb/resources/provider_types/2009_0526_emqahistory.shtml

Q 8. Is chief complaint required for interval history in a nursing home?
A 8. The chief complaint is the reason for the visit. Documentation for all E/M must include the chief complaint.


As to your other chief complaint question, the cc drives the history which drives the exam, which results in the medical decision making. If you don't have a cc you can't support doing any of the E/M.

Maybe your provider has a documentation style issue that just needs to be addressed, but the cc should be established if not before the history somewhere in the history portion of the note. 

Laura, CPC, CPMA, CEMC


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## abhishekrane32@yahoo.com (Oct 3, 2012)

even i find missing CC in many subsequent hospital records.. as per EM guidelines CC must be documented anywhere in progress note. IN most of the time i find CC  documented in HOSPITAL SUMMARY or  below assessment and plan in subsequent visits which can be considered.

abhishek rane


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## AmandaW (Oct 4, 2012)

Thank y'all very much!  Sometimes the notes that are written out will have a pretty well laid out format-I can see where the exam is & Assessment and Plan, but because you only need 2 out of 3 they won't put much history or any at all on top-but I'm still good with my exam and MDM. 

So bottom line is, you will usually find the c.c. in the HPI or even seperately documented on top, BUT it does not HAVE to be in the history, correct?  

Example:  Nothing for history documented. 
               Physical Exam done. 
               MDM done (A/P)  
               Patient has 2 diagnoses

As long as I still have enough documentation for my MDM, can I pick the #1 
diagnosis as my chief complaint that  happens to be documented in the Assessment and Plan?


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## LLovett (Oct 5, 2012)

*CC is an element of history*

CC is especially important in the inpatient setting. You most often have multiple providers seeing the same patient. There needs to be medical necessity for each provider that is involved. Each entry must stand alone, you can not count a CC from any other visit.

I would really love to see documentation that supports you can pull a CC from anywhere, including other notes. 

Laura, CPC, CPMA, CEMC


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## AmandaW (Oct 9, 2012)

I see it as an element of the history as well but I can't find anything that says that it HAS to be.  I see in guidelines where it "can" be seperately stated or "can" be found in the HPI.  I don't see where it says it can't be anywhere else but I only find it talked about in the 'history' portion so I would assume it has to be in the history.   (Trying to prove that to others).  

Chief complaint is one of those things that has always kind of been confusing to me.  I think obviously you would need one for a Dr's office, PCP, specialty, etc....but a hospital note shows the obvious reasons why a patient is in.  They could feel just fine, no complaints at all, but be very very sick and and in need of inpatient hospital attention.  I've had Doctors point that out to me themselves.  It just seems redundant or useless for it to be stated-the Assessment and Plan tells why they are there.   Just want to make sure before printing these records out to send back for them to simply amend a note stating c.c. kidney stone that it IS absolutely necessary.  Just don't understand why we should have to take out the time to print it off, fax it to them, wait for it to come back and then finally be able to bill it when the remainder of the note clearly reflects the reason their in the hospital.  That reason could even be found in the exam.  Basically anywhere there's a diagnosis.


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## LLovett (Oct 9, 2012)

The physicians chief complaint is not supporting why the patient is in the hospital, it is supporting the reason it is medically necessary for that physician to see the patient that day.

Just because a patient is sick enough to require inpatient treatment and a physician sees that patient does not make that visit medically necessary.

It is somewhat common in fact for physicians to see patients for no other reason than the fact that they are patients of the physician and they are in the hospital. Or the patient is being discharged to say a nursing home but they don't have a room so the patient is stuck in the hospital a few extra days after discharge. These visit are of a social nature and are not billable.

If a patient is in house for say a hip replacement, ortho is managing the patient. They are also diabetic and have hypertension, both controlled. Ortho calls in the primary care since they have these other issues. PCP sees patient says all is good carry on. This visit is billable. Patient is in the hospital for say 2weeks, nothing going on with the DM or HTN, primary stops by every day, says patient is doing well and procedes to list all the reasons the patient is in the hospital in their assessment. Where is the medical necessity for these visits? 

I have also found that sometimes hospital policy dictates who sees the patient and when, this is fine but you need to realize that hospital policy may not coincide with medical necessity as defined by those who are paying the bills.


Laura, CPC, CPMA, CEMC


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## tammymlance (Oct 11, 2012)

I need input..... I "dinged" a physician for no "CC".  As most coders are well aware that every visity (with the ONE exception of the preventative) needs a CC.  
The response I got from him was "9 month olds typically cannot give a CC".  The HPI was documented by the mother..... but my stance is that the CC would also be documented by the mother.  
Can anyone give me a reference point to let him know?  (This is our director).
Tammy


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## MnTwins29 (Oct 11, 2012)

*Thank you!*

This thread is valuable for us, as I have been contacted by our chief Hospitalist to give education on their E/M levels.   This discussion, especially Laura's contribution, will be helpful for my research.

As for the CC being documented only in the history, that makes sense.   The CC does have to be in the patient's words, not the physician's, and that couldn't come from the exam (objective) and in the assessement or plan since that is again the provider's judgement, not the patient's.


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