Wiki Chief Complaints - Can someone help me

[toliverson]

Can someone help me with a discussion I'm having with our doctor? I've tried to explain that the chief complaint should be a concise statement in the patient's words but he wants to use quick text if possible. I've listed below his suggestions but I don't know about some of them. I like using “Spot on nose. History of BCC” or “Rash on back” because that's what the patient's are stating as their reason for the encounter. Any suggestions???

Skin cancer detection, personal history of skin cancer
Skin cancer detection, history of pre-cancers
Skin cancer detection, history of significant sun damage
Skin cancer detection, history of atypical nevus/nevi
Skin cancer detection, family history of skin cancer
Skin cancer detection, high risk pt with history of immunosuppression

 

[cschenk]

The Cheif Complaint is a subjective statement by the patient. If you read the AMA CPT guidelines for E/M coding, it states, "A chief complaint is a concise statment describing the symptom, problem, diangosis, or other factor that is the reason for the encounter, USUALLY STATED IN THE PATIENT'S WORDS". These are AMA guidelines, and in an audit by any carrier or Medicare or the OIG for that matter, are strickly followed. So I would definitely stress the importance to your provider that the AMA guideline is stating the CC must be in the patient's words and if not, the provider could have legal issues on their hands by larger organizations or even federal entities. I would alss show the provider the exact wording in your CPT book. Guidelines are a power tool to use.