Wiki Chief Complaint question

[jlb102780]

Good Afternoon,

I have a question on documenting the Chief Complaint. We are a large Cardiology group. I have started to notice on some of the encounters that the CC is only being documented as "presents for Annual and Evaluation". Would this be considered a prevenative service? I'm asking because I came across an article posted on AAPC that said:

"If the patient doesn?t have a problem (for instance, she just needs an annual exam), there is no chief complaint. You must bill a preventive E/M service."

http://news.aapc.com/index.php/2013/03/8-tips-for-compliant-history-component-documentation/

Now most of our patients are well established with us, and with multiple cardiac conditions being addressed. I'm not sure if these would fall under a prevenative service, but with the CC only showing as "annual", I'm not too sure if a regular E/M is meeting guidelines as well.

Any thoughts??

Thanks,

 

[kaywil2]

Chief Complaint Question

If the patient is being seen for chronic active problems this physician has been treating, you may use the CC of: f/u of (list conditions).
That being said the physician must give status of each of the conditions he/she is seeing the patient for in their HPI.