EM Coding Alert

Question: Our otolaryngologist lists the chief complaint (CC) for all follow-up visits using just “f/u” — we have never had an issue collecting payment, but our coder is concerned that this isn’t compliant. Can you advise?

Illinois Subscriber

Answer: The chief complaint is not thorough enough, and if the physician writes the same thing on every record, he could even be at risk of accusations of “cloned notes” or, more importantly, providing medically unnecessary services. The chief complaint establishes the medical necessity for the encounter.

First and foremost, avoid “follow-up” as a catch-all complaint. All E/M documentation must include a chief complaint, but what your otolaryngologist lists as the chief complaint may not fit your payer’s requirements. The chief complaint is considered by insurers to be a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the E/M encounter. It is typically stated in the patient’s own words.

Otolaryngology practices, for example, might include increased nasal congestion or throat pain. Just stating “follow-up” is not appropriate. However, it is appropriate to say “follow-up nasal congestion.” If a patient is coming in for lab tests, put the reasons (signs and symptoms) that the lab tests were performed as the chief complaint. Whenever in doubt, the patient’s signs and symptoms are always safe add-ons to the “follow-up” in the chief complaint.

In addition, whether the cloned documentation is handwritten, the result of a pre-printed template, or through the use of electronic health records (EHRs), cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services. Therefore, you should never have documentation with the same information listed over and over again, because this could create compliance issues. Speak with the physician in question and educate him on appropriate coding techniques to avoid this issue in the future.