Medicare Compliance & Reimbursement

Hail to the chief complaint--even if it's at the end of the note.

Getting dinged on audits because you don't have a chief complaint listed at the top of your physician's note? Don't give up until you check the "assessment" section of your note.

The problem: Official guidelines say that the chief complaint, the main reason for the patient's visit, must appear at the top of the physician's note or in the history of present illness (HPI) section, says Jim Collins, president of The Cardiology Coalition in Matthews, NC.
 
The solution: "In the real world, the reason for the visit is frequently listed in the 'assessment' section of the note," which usually appears towards the bottom, says Collins. You can argue that your doctor really did record a chief complaint, and that "the reason for the visit is documented in the 'assessment' section." This could get you through "a tough audit situation," says Collins.
 
The guidelines don't stipulate that the chief complaint can appear in the assessment situation, but they do say that the doctor can list the complaint "as separate elements of history" or include it in the HPI, Collins points out. As such, "we may be able to argue that the chief complaint for many visits is documented in the assessment/plan section of these notes," he adds.

Problems with the doctor failing to list the chief complaint are most common in subsequent hospital care services (codes 99231-99233), says Collins. The American Medical Association says the chief complaint should be in the patient's own words.

What to do: To avoid having to dig into the assessment section of the doctor's note, encourage your doctor to write "c/c" at the top of the visit notes. After this, the doctor should write "a word or two explaining why the patient needs to be seen by a cardiologist." The doctor could write simply, "follow-up for CAD," "unstable angina" or "A-fib."

Encourage your doctor not to write vague statements like "feeling better", "feels well," "much better," "comfortable" or "resting quietly" as the chief complaint, Collins urges.