Part B Insider (Multispecialty) Coding Alert

Chief complaint need not be at the very top of the note, but the physician must state it clearly.

Getting dinged on audits because you don't have a chief complaint listed at the top of your physician's documentation?

Don't give up until you check the entire note. Although you'll benefit from a chief complaint documented clearly at the beginning of the note, Medicare doesn't require that you list it at the top.

"The chief complaint should be clearly illustrated," says Suzan Berman (Hvizdash), CPC, CEMC, CEDC, senior manager of coding and compliance in the departments of surgery and anesthesiology University of Pittsburgh Medical Center. "Listing it amongst the assessment might not paint the clearest picture. There might be other issues that came out in the visit (or other conditions the clinician is concerned about as they relate to the chief complaint or the possible treatment options), but, they might not be the exact complaint."

The 1995 and 1997 CMS Documentation Guidelines indicate that the chief complaint, review of systems, and the past family social history may be listed as separate elements of history, or they may be included in the description of the history of the present illness (HPI), notes Sherry Gann, CPC, with Shawnee Health Service in Carterville, Ill. "Therefore, the chief complaint can't just be anywhere on the record," Gann says. "It must either be listed separately or in the HPI."

Important: "The guidelines don't come out and say 'it must be at the top of the note,' but the guidelines are very clear that the chief complaint should not be implied but stated clearly," Berman says.

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 physician. 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.

Who can record it: Medicare carriers differ regarding which staff members can document the chief complaint. WPS Medicare, for instance, the Part B payer in four states, notes that "the 1995 and 1997 Documentation Guidelines do not address who can record the chief complaint [CC]. WPS Medicare will allow the chief complaint when recorded by ancillary staff. However, the physician must validate the CC in the documentation."