Wiki Chief complaint

[kdziekan]

Can someone please provide a coding organization specific or government regulated link (not just MAC's, but CMS) to support that the physician MUST document/validate/reiterate/etc. the chief complaint. The CMS E/M Service guide does not list this as something ancillary staff can document, however, we need very clear verbaige to support that it HAS to be documented by the physician. Please help! Pleae provide link/site/resource in addition to excerpt where it clearly defines this.

 

[OCD_coder]

1995 Documentation Guidelines:
DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.

The guidelines are pretty clear that ancillary staff is limited to just recording the ROS and PFSH. It would be redundant to make a statement that the physician should document the Chief Complaint or any other E&M component. This is how the coding industry interprets the information.

As a general rule: Any history information entered by someone other than the provider needs to be authenticated by the provider.

Here is supplemental source with a modified interpretation:

http://www.medtronsoftware.com/pdf/2013/070113_Educational_Series_E&M_Auditing.pdf

 

[LLovett]

I am going to disagree with the statement the physician has to document the chief complaint. If you search back over the years you will see myself and others discussing this issue in depth multiple times.

The physician does have to validate/support the chief compliant by doing and documenting the work resulting from the chief complaint. If the chief compliant is not supported by the providers note then that is no longer a valid chief complaint and one would have to be pulled from the providers documentation. So in that case it is required that the provider document a chief complaint.

Just my input for what it is worth.

Laura, CPC, CPMA, CEMC

 

[RebeccaCross*]

My MAC states...

Jurisdiction 11 Part B

What specific information can ancillary staff (e.g., RN, LPN, CNA) document during an evaluation and management (E/M) encounter? Can ancillary staff act as a scribe for a provider?
Answer:
Ancillary staff may only document:

?Review of systems (ROS)
?Past, family and social history (PFSH)
?Vital signs
These three areas must be reviewed by the physician or non-physician practitioner (NPP) who must write a statement that it is reviewed and correct or add to it.

Only the physician or NPP that is conducting the E/M service can perform the history of present illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff. In certain instances, an office or emergency room triage nurse may document pertinent information regarding the chief complaint (CC)/HPI, but this information should be treated as preliminary information. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail.

http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/8EELQE6434?open