# No Chief Complaint



## ErinGaillard (Jul 2, 2018)

I am coding E/M for a pulmonology office, mainly hospital critical care, consults, and progress notes. Doctor B never, EVER has a separate chief complaint documented. Doctor A,who runs the practice, hired me to look for errors and help fix them to keep from being audited. How do I approach this issue with the chief complaint? I've reviewed 100 charts, and there have been absolutely zero with a chief complaint....technically can those even be sent out? Not sure how to handle it.


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## Pathos (Jul 2, 2018)

I have sometimes pulled the chief complaint from the HPI instead from a designated "box" in the EHR, however even CMS explicitly state that a CC is required for an E/M visit. This could be a local policy though, as I am not so familiar with First Coast MAC (_or depending on where your provider practices_).

However, you were hired to do an auditors job and should do so. Depending on your agreement with Dr. A (_how much authority you have been given, your audit and reporting process_), I would at the very least report your findings back to Dr. A. If you are supposed to share your finding directly with Dr. B, then make sure Dr. A is included in your correspondence. Provider communication can be tricky though, but the hope is that they will at least respect you for trying to shield them from future serious audits and worse.

Hope that helps!


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## twizzle (Jul 3, 2018)

*No chief complaint*



ErinGaillard said:


> I am coding E/M for a pulmonology office, mainly hospital critical care, consults, and progress notes. Doctor B never, EVER has a separate chief complaint documented. Doctor A,who runs the practice, hired me to look for errors and help fix them to keep from being audited. How do I approach this issue with the chief complaint? I've reviewed 100 charts, and there have been absolutely zero with a chief complaint....technically can those even be sent out? Not sure how to handle it.



Is there anything in the HPI to indicate why the patient is seeing the provider? In an ideal world we would want our provider to say "Chief complaint; follow up for HTN". Unfortunately this often doesn't happen.
You can use the HPI for the chief complaint as long as the cc is easily inferred. It should be, but does not have to be, a separate statement.


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## thomas7331 (Jul 3, 2018)

I coded and audited hospital E/M services for a couple of years and I'm not surprised to hear you say this.  It's been my experience that the chief complaint is less of a concern to both physicians and coders/auditors on inpatient services because each E/M service is really one piece of the whole narrative of the hospital stay and although theoretically should stand 'on its own', it almost by definition cannot because is just one chapter in the record of that admission.  The chief complaint for inpatient services is really either the reason for the admission to the hospital or a new complication that has occurred since the time of admission, and it doesn't make much common sense to require the physicians to restate it on every daily visit when the information is already in the chart.  

That said though, the guidelines are the 'letter of the law', so to speak, and say that every E/M service should have a chief complaint, so the best way to protect your physician in the event of an audit by a strict or unsympathetic auditor would be to include a brief statement at the start of each note that succinctly states why the physician is seeing the patient that day, so that would be the advice I would give to the physician.  It takes minimal effort to do this, as Pathos' example above shows, which could even be simplified further to just 'CC: F/U HTN'.


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## NiteshlalKoyalkar (Jul 5, 2018)

HI, 
In this kind of scenario i would suggest you to share the medical record without any PHI information on it. this helps us to actually review the record and give you appropriate reply. 
thank you.


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