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Hello,
I work for a Nephrologist practice and we are always being referred by the patients' primary care physicians. These patients range from middle age to the elderly. When they come in half the time they do not know "why" they are coming in. When asked what brings them here they say, "I don't know, my PCP asked me to come see you." So with this being said, how can my physicians document the Chief Complaint, when according to the CPT it states that the "chief complaint is usually given by the patient." If there is no Chief Complaint to document, then I am assuming there is no HPI either? Or can the physician obtain the chief complaint through the medical records fron the PCP along with the referral form with the reason itself? This question refers to both office visits and hospital non-facility coding/billing. Our physicians to do not work for the hospital.
The reason I am asking this question, is that I have a physician that will not document the chief complaint in his notes if the patient does not know why they are being seen. No chief complaint, documents a detailed HPI, but cannot find the "primary" reason for the visit. If anyone can guide me to a webpage or literature regarding that it's ok for the physician to document the Chief Complaint (primary reason for the visit) I would greatly appreciate it. He wants proof that he can.
I went throught Noridian AZ, and all I find is the rules on the chief complaint as to whi can document it...
Thanks members!
I work for a Nephrologist practice and we are always being referred by the patients' primary care physicians. These patients range from middle age to the elderly. When they come in half the time they do not know "why" they are coming in. When asked what brings them here they say, "I don't know, my PCP asked me to come see you." So with this being said, how can my physicians document the Chief Complaint, when according to the CPT it states that the "chief complaint is usually given by the patient." If there is no Chief Complaint to document, then I am assuming there is no HPI either? Or can the physician obtain the chief complaint through the medical records fron the PCP along with the referral form with the reason itself? This question refers to both office visits and hospital non-facility coding/billing. Our physicians to do not work for the hospital.
The reason I am asking this question, is that I have a physician that will not document the chief complaint in his notes if the patient does not know why they are being seen. No chief complaint, documents a detailed HPI, but cannot find the "primary" reason for the visit. If anyone can guide me to a webpage or literature regarding that it's ok for the physician to document the Chief Complaint (primary reason for the visit) I would greatly appreciate it. He wants proof that he can.
I went throught Noridian AZ, and all I find is the rules on the chief complaint as to whi can document it...
Thanks members!