Part B Insider (Multispecialty) Coding Alert

No symptoms doesn't mean no reason for the patient to be there

If your doctor is in the habit of marking -patient has no complaints- or -asymptomatic- on documentation, then you may have a big problem of your own.

The problem: Every Medicare visit must have a -chief complaint,- or the main reason why your physician is seeing the patient. Even if your patient is just coming back because the doctor instructed him or her to come back in six weeks, there's still a reason for the patient's presence.

If the doctor just notes -check-up- as the chief complaint, you only have a preventive visit, which Medicare generally won't pay for, notes consultant Maxine Lewis with Medical Coding Reimbursement Management in Cincinnati.

Call your doctor: If there's no diagnosis, or it's unclear which diagnosis is the chief complaint, you should ask your physician for clarification, suggests Joan Logue, principal with Health Systems Concepts in Longwood, FL.

Look to history: Usually, the doctor can pull the chief complaint out of the patient's history. Maybe the patient is coming back because of past rectal bleeding, suggests Linda Parks, coding specialist at GI Diagnostics Endoscopy Center in Marietta, GA. So the chief complaint should be -follow-up for rectal bleeding.- Ditto for chest pain or other complaints that may bring the patient back for a follow-up.

Provider should note: Even if your coder can figure out the chief complaint from other clues in the documentation, you should still clarify with the doctor, says Lewis. It should be up to the doctor to note the chief complaint.

In some cases, the nurse or the medical assistant can write the chief complaint on the top of the form before the doctor sees the patient, suggests Parks. Then the doctor can come in and initial the chief complaint at the start of the visit. -If you can get your medical assistant or your back office nurse to chart your chief complaint, you-re ahead of the game before your doctor even goes in,- Parks explains.

Warning: The chief complaint cannot be preprinted or computer-generated, notes Parks.

Two out of three ain't bad: If the patient is an established patient, you may be able to use the physical exam and medical decision-making, and skip the history portion, notes Lewis. That means you may be able to bill an E/M visit without a chief complaint. But for consults and new patient visits, you need a chief complaint, she adds.

-But why is the patient there?- asks Lewis. -A good physician will tell me why the patient is there.-