Pediatric Coding Alert

Question: Our pediatrician documents most of his chief complaints as “follow-up” (for established patients) or “establish care” (for new patients). I have told him this is not a compliant chief complaint but he refuses to believe me. Who is right?

Answer: It sounds like you are. If the notes said “Establish care and perform complete preventive physical” or “follow-up to otitis media visit on Jan. 1” then the chief complaints you’ve described would be more accurate, but as it stands, they are not adequate. The reality is that all E/M documentation must include a chief complaint, but what your physician lists as the chief complaint may not fit your payer’s requirements.

The chief complaint is 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. An example would be a sore throat, or chest pain. Just stating “follow-up” is not adequate.

Where the chief complaint is found: Although some coders were trained to only look for a chief complaint in one particular section of the documentation that is inaccurate. The chief complaint may be listed as a separate element of the history, or it may be included in the history of present illness (HPI) in some cases.