# Chief complaint help needed! Already went through the threads..



## Love Coding! (Jun 14, 2012)

Hello,

I work for a Nephrologist practice and we are always being referred by the patients' primary care physicians. These patients range from middle age to the elderly.  When they come in half the time they do not know "why" they are coming in.  When asked what brings them here they say, "I don't know, my PCP asked me to come see you."   So with this being said, how can my physicians document the Chief Complaint, when according to the CPT it states that the "chief complaint is usually given by the patient."  If there is no Chief Complaint to document, then I am assuming there is no HPI either?  Or can the physician obtain the chief complaint through the medical records fron the PCP along with the referral form with the reason itself?   This question refers to both office visits and hospital non-facility coding/billing.  Our physicians to do not work for the hospital.  

The reason I am asking this question, is that I have a physician that will not document the chief complaint in his notes if the patient does not know why they are being seen. No chief complaint, documents a detailed HPI, but cannot find the "primary" reason for the visit.  If anyone can guide me to a webpage or literature regarding that it's ok for the physician to document the Chief Complaint (primary reason for the visit) I would greatly appreciate it.  He wants proof that he can.  

I went throught Noridian AZ, and all I find is the rules on the chief complaint as to whi can document it...

Thanks members!


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## lburke31 (Jun 14, 2012)

we have patient state why they are coming at the time an appt. is made. most specialists we refer to ask that we send an rx with the patient to explain what the issue is. my coding book states that if the physician is unable to obtain a history, the record must describe the circumstances that precludes obtaining the history. if you end up calling referring office, you can at least count that as part of your mdm. somehow or other a cc must be on note.another suggestion is to ask local med society for advice. personally, i would put burden on pt to provide that info before they arrive. ljb


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## Love Coding! (Jun 14, 2012)

lburke31 said:


> we have patient state why they are coming at the time an appt. is made. most specialists we refer to ask that we send an rx with the patient to explain what the issue is. my coding book states that if the physician is unable to obtain a history, the record must describe the circumstances that precludes obtaining the history. if you end up calling referring office, you can at least count that as part of your mdm. somehow or other a cc must be on note.another suggestion is to ask local med society for advice. personally, i would put burden on pt to provide that info before they arrive. ljb



Thank you for responding, I agree with what you are saying in regards to placing the burden on the patient to obtain the primary reason as to "why" they are coming in to see our specialists.  However, in their defense there are many reasons that their PCP stumbles upon to prompt the visit with us, the primary reason "abnormal labs".   Within our specialty Nephrology it's all lab results related, sometimes there are no "symptomatic" complaints to report from the patient.  So this is where I am stuck.  So do we "ding" the physician because the patient cannot come up with a "chief complaint"???  Dropping them from a level 5 office visit down to a level 2 or not able to bill the visit all together??


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## Love Coding! (Jun 14, 2012)

*Anyone else?*

Has anyone else encountered my situation?  I am very curious on what others' may think of this issue?  Please respond, I do not want to educate my physicians on something that I am not sure of.

Thank you


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## Gainingknowledgedaily (Jun 14, 2012)

I have a resources on Chief Complaints but they are from WPS, Minnesota. So let me know if you don't mind.


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## ollielooya (Jun 14, 2012)

I identify with your frustration in waiting for answers to your issue.  I hope you get some soon and wish I could provide some help.  My thoughts are that the definition of chief complaint has that tricky little phrase, ---"or other factor that is the reason for the encounter, usually stated in the patient's words." Is it possible to build on this _other factor _to come up with the chief complaint?  I guess, in essence, that is what you are trying to do...watching this thread closely as I may be the one asking the same question one day.


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## FTessaBartels (Jun 14, 2012)

*Chief complaint does NOT mean diagnosis*

The chief complaint does not mean the diagnosis.   It would be perfectly acceptable to see:
Chief Complaint: patient referred by PCP for abnormal labs

I agree with trying to get this information from the patient at the time they call for an appointment.  I also understand that patient's are not physicians and don't always understand or absorb the information given to them.  

I definitely WOULD accept the differential diagnosis of the PCP when making the referral as the chief complaint ... but I'd expect to have received a specific referral form (or request for consult) that included the reason for the referral/request. 

The diagnosis would depend on what the provider found on this examination and any diagnostic tests performed.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## Love Coding! (Jun 14, 2012)

*Wow*

Thanks everyone for your input.  It really helps when you feel like you are not the only one dealing with this issue.   Hi Tessa, thank you for the feedback, at least I can let him know that it is acceptable to obtain the chief complaint from the PCP as long as there is physical documented proof that the stated diagnosis is the primary reason for the visit.  I have to laugh about this, but it amazes me how ambiguious CMS and the AMA is with their guidance.  I guess it's the mystery behind trying to find an answer to keep us interested in doing this line of work...

Thanks again everyone...


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## Love Coding! (Jun 14, 2012)

llcullen said:


> I have a resources on Chief Complaints but they are from WPS, Minnesota. So let me know if you don't mind.



Thank you llcullen that would be great!


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