Wiki Level of E/M with of CC

[sandhyaRani]

Hi, can anyone tell how to evaluate the E/M level if the document came without cheif complaint. Is there anyway to evaluate the level without cheif complaint. Plz post the answer.

Thanking you
Sandhya CPC-A

 

[Ahamed Fahath]

Hi,
It is not mandatory that CC should be mentioned in a seperate heading. Try your best to pick the CC from chart. It may be in HPI. If you cannot pick it anywhere from the chart then send back to the provider for asking CC.

 

[Naveen Rachagolla]

CC

A Chief Complaint is a concise statement describing the symptom, problem, diagnosis, or other factor that is the reason for the encounter. usually stated in the patients words.

For example, patient complains of upset stomach, aching joints, and fatigue. The
medical record should clearly reflect the CC.
For Example: A Medical record can be like this...

Patient/AGE: XXXX/10 years DOS: 12/23/XXXX


Temperature, sore (throat 1).[ Headache, congested, ("bad" 2) (cough 3,4)] x (5 days 5), (worse at night 6). (Meds: Wellbutrin 7), Phenergan DM. (Denies other respiratory or neurologic complaint.8 )

1 HPI: Locations- Throat
2 HPI: Severity-Bad
3 Chief Complaint-cough
4 HPI : Associated signs/symptoms- Headache, congested,
5 HPI : Duration- 5 Days
6 HPI : Timing- worse at night
7 Past History- Wellbutrin
8 ROS: Respirator and Neurological