# Chief Complaint - A patient came into the office



## Crystal H (Sep 7, 2010)

A patient came into the office for a nurse visit for spirometry (This was documented by the nurse). The visit turned into a level 4 by seeing our Physician.  My question is:  He starts out by stating Addendum:  The documentation does not state Chief Complaint instead he documents as: Subject: Acute Dysuria  If audited, would SUBJECT work as Chief Complaint?  He goes on as:  Additional Information: Total Time 15/25 minutes devoted face to face...  Review of Systems - all documented.   Testing: UA    Reviewed/Discussed/Detained = all documented.    Medication: ordered to start .....   Return to clinic ....     PLEASE answer ASAP.

One other question:  Sometimes pt comes for preventive visit which turns into regular office visit.  Is there a certain amount of time needed for the preventive physical?

Thanks for your help.  It is truly appreciated.


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## RebeccaWoodward* (Sep 7, 2010)

The documentation guidelines state that "the medical record must clearly reflect the chief complaint". If you can identify the reason for the visit, you have your chief complaint.  Since the physician identified an additional problem oriented issue, this would suffice. 

Preventative exams are not time based.  The physician selects the appropriate service based on age and whether the patient is new or established. Just make sure that you separate the elements for the problem oriented complaint so that you're not using the same elements for both your PE and problem oriented E/M. The problem oriented E/M needs to be able to stand on its own.


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## Crystal H (Sep 7, 2010)

*Chief Complaint*

Rebecca,
Thank you soooo VERY much.  I am not a certified coder although, I do hope to be one someday.  I am from the old school and not use to all this auditing stuff.  Do you happen to know a good book which would educate me on the e/m guidelines?  My previous employer (Physician) did all the e/m coding.  All I did was bill.  My recent employer is right out of school and guess who does the auditing?  Me.  You are a life saver!!!!
I have one more question.  Let's say a patient comes in for preventive (which I know is not based on time.  Thanks to your answer.  He spends alot of time with the patient giving extra counseling, mother discussing patient has behavior problems at school...  so the question is : Can he do a pro long code in addition to the preventive code.  If so, how much time?  Thanks again.
Crystal


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## RebeccaWoodward* (Sep 7, 2010)

The 1st link is the link to CMS's documentation guidelines.

https://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp

The 2nd link is a wonderful site with lots of free information.

http://emuniversity.com/

You can't use the prolonged CPT codes (99354/99355) with the preventive section.  Per CPT, 99381-99397 include counseling/anticipatory guidance/risk factor reduction interventions.  CPT directs you to report 99401-99412 (preventive medicine counseling) for reporting those services that are provided at an separate encounter.

Deb Grider has a wonderful book titled "Medical Record Auditor" but I would try the websites provided until you really get your feet wet.


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## Crystal H (Sep 7, 2010)

Once again Rebecca,Thank you so much!!!!!  Looks like I have alot of reading to do from these web sites.
Crystal


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## losborn (Sep 8, 2010)

The courses at E/M university are really really cheap.  I would ask my doc to spring for the $100, and then you WATCH THEM TOGETHER.  He will probably increase what he can bill for after incorporating these ideas - AND provide appropriate care.

The guy is an MD, so your physician might not mind watching him.  It is actually the first webinar I've seen where I didn't want to speed up the sound!

Lin
CPC


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## MnTwins29 (Sep 9, 2010)

Agree with losborn - Dr. Jensen gives fantastic presentations, and it is in clear language for both physicians and coders.  Something else to consider from the site - the E/M case of the week.  He gives a progress note, and you vote for the correct code.  You are then taken to a video of Dr. Jensen explaining the breakdown of the three key elements to come up with the code.  I look forward to that every week!


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## laplit (Jun 1, 2018)

What is your nurse visit spirometry workflow process?  What is the nurse documenting?  Is anyone else bringing in patients for spirometry testing during nurse visits?


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