# Chief Complaint



## hthomson (Apr 24, 2013)

Help.  I am new to the auditing process.  One of the training tools I was given states that you cannot use the information in the chief complaint as a countable element in the hpi.  An example would be CC: Patient here for f/u of depression and anxiety.  The note then flows right into the Subjective.  Am I able to use the depression and anxiety as two chronic problems?  Thank You


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## btadlock1 (Apr 24, 2013)

luckyinlove said:


> Help.  I am new to the auditing process.  One of the training tools I was given states that you cannot use the information in the chief complaint as a countable element in the hpi.  An example would be CC: Patient here for f/u of depression and anxiety.  The note then flows right into the Subjective.  Am I able to use the depression and anxiety as two chronic problems?  Thank You



The chief complaint *can* also be HPI - you can't share HPI with ROS or PFSH. I wouldn't list this as 2 chronic problems, unless there's also documentation of the current status of the problems, and their treatment plan. I would score that as brief HPI, based on 1 element - associated symptom. I actually wrote an article over the History component, that might help you...

Go here: https://www.aapc.com/resources/publications/cutting-edge/archive.aspx
It's in the May 2013 issue, page 48...

Hope that helps!


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## maine4me (Oct 18, 2013)

I recently was asked to audit some charts which had been audited by an outside billing company that we use for one of our groups.  Quickly, I could tell that I was looking at the work of multiple auditors, and I know we could get 6 coders in one room and everyone could come up with the same E/M but we may get there in a slightly different manner.  Here is my question, one of the auditors did not count the chief complaint because it was not in the first person.  The patient was being seen in follow-up for breast cancer (this was the documented CC).  I know the CC should be in the patient's own words, but is it necessary that it be in the first person?


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## MnTwins29 (Oct 18, 2013)

I would love to see where this auditor found that a CC must be documented in the first person.   For a F/U visit, what is supposed to be documented - "I am here for my Breast Cancer check up"???    Or take visits for pain - most charts will say "knee pain", "abdominal pain" , whatever.   Not "My Knee Hurts" or "I have a tummy ache."


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## MarcusM (Oct 18, 2013)

If we had to put CC into the patient's own words, our CC would be paragraphs, not a brief CC. "Well, last week my third cousin from east Texas came visitin', and we sat on the porch for awhile when the dog got to chasin' the cat and the cat ran right up on the front porch and commenced to clawin' her way up my legs...why, there was cat fur and dog fur flyin' every which way and then the postman showed up.  When I got up, I tripped over the dog and fell off the porch and hit my head.  Blood went everywhere and I got a bunch of stitches from my neighbor who is one of them EMS people.  I hurt everywhere and that's why I came to see the doctor."


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## mhstrauss (Oct 18, 2013)

MarcusM said:


> If we had to put CC into the patient's own words, our CC would be paragraphs, not a brief CC. "Well, last week my third cousin from east Texas came visitin', and we sat on the porch for awhile when the dog got to chasin' the cat and the cat ran right up on the front porch and commenced to clawin' her way up my legs...why, there was cat fur and dog fur flyin' every which way and then the postman showed up.  When I got up, I tripped over the dog and fell off the porch and hit my head.  Blood went everywhere and I got a bunch of stitches from my neighbor who is one of them EMS people.  I hurt everywhere and that's why I came to see the doctor."




Where can I nominate this for "Best Answer Ever"??  That just completely made my Friday!!


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## maine4me (Oct 18, 2013)

Marcus this is the best answer!!  You made my week!!

Another question,I have visits notes that lack an HPI/Interval history, and exam.  One of the auditors chose a code based on the MDM alone.  I would think if neither of the other elements were documented the charge is either non billable, or would simply go to the lowest level code.  How do other auditors hadnle this situation?


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## mlbaker1974 (Nov 2, 2013)

MDM should be the driving force behind your level choices but the guidelines still say that for a new patient all 3 components must be met and for an established patient 2 of the 3 components must be met. So I think coding on MDM alone would be very risky.   
However, the providers need to be familiar with thier contracts with carriers because some carriers require that the MDM component be one of the 2 key components for outpatient encounters.

Not sure if I made sense but I hope I helped.


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## LGillstrom (Nov 5, 2013)

maine4me said:


> I recently was asked to audit some charts which had been audited by an outside billing company that we use for one of our groups.  Quickly, I could tell that I was looking at the work of multiple auditors, and I know we could get 6 coders in one room and everyone could come up with the same E/M but we may get there in a slightly different manner.  Here is my question, one of the auditors did not count the chief complaint because it was not in the first person.  The patient was being seen in follow-up for breast cancer (this was the documented CC).  I know the CC should be in the patient's own words, but is it necessary that it be in the first person?



CPT has this to say regarding the Chief Complaint: 

_A chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reson for the encounter, usually stated in the patient's words_

Please make note of the word "usually" which indicates that it does not _have_ to be in the patient's own words.

The Medicare Physician Guide says:

_The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter

DG: The medical record should clearly reflect the chief complaint_

I would, at the very least, query the auditor for a citation for her rationale for not counting the CC when not in the "patient's words".  I do not believe that her findings are correct.

Hope this helps!


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