Wiki CC

[LTibbetts]

We are having somewhat of a debate in my office over the documentation of the CC on an ER medical record. After looking over the guidelines, they seems to be a little ambiguous about it. It doesn't say that it is required but it does say that it should be there. There is another part where it says that it can be taken from the HPI, is that ok? Is this one of those gray areas that are left up to the individual coders interpretation? I was always under the impression that it had to be there but now I don't know and I actually trust some of you more than anyone in my office when it comes to proper E&M coding principals....

 

[LindaEV]

There SHOULD be a CC, and the E/M guidelines say so. But, it can be taken from the HPI, and doesnt have to be seperately documented under a "CC" heading...Some docs like to throw their CC/HPI/ROS all into one big blob of a paragraph. You can pick apart, just not use twice.
In the CPT book, under the heading of "Instructions for Selecting a Level of E/M Service", it has "chief complaint" listed first under the description of each level of history. (I have an Expert CPT, but I think these guidelines are in reg CPT book).

 

[Walker22]

In the 1997 E&M Documentation Guidelines it states that a chief complaint is indicated at all levels of the HPI. It's just above the table at the bottom of page 5 (the 7th page including the cover sheet..).