Wiki Chief complaint for Inpatient

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mrsmason95

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I code for a Cardiology office in Georgia, and was just told that you don't necessarily have to have a chief complaint for inpatient rounds, if the note tells why the physician is rounding on the patient.

Does anyone know this to be true? Is there any references that you have for this jurisdiction that states this.

I thought ALL E/M codes required a chief complaint in order to send out the claim.
 
There absolutely needs to be a chief complaint. If there is no cc, there is no reason to bill an E/M. It doesn't necessarily have to be stated as chief complaint. MD can state following patient for SOB, or CP or Afib, etc. CC can als be patient being evaluated for CABG.
 
Well, a"so-called" consultant told me that for inpatient visits, you don't have to have a chief complaint, you could use the problem list. Even though there were other diagnosis on the problem list that a cardiologist wouldn't see a patient for.

I just wanted to know if anyone else agreed with this and could provide "Valid" reference to back this up.
 
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