Disclaimer
This article and the related comments are for educational and discussion purposes. They do not establish the standard of care in every patient’s situation. In each patient’s situation, the treating physician or other medical professionals must exercise their professional judgment. Similarly, these materials are not medical advice to patients, who must consult with their own physician or other medical professional.
The CMS 1995 Documentation Guidelines for E&M Services begins with a list of general principles of medical record documentation. Number two on the list behind “the medical record should be complete and legible” is “the documentation of each patient encounter should include a reason for the encounter” (chief complaint). The Guidelines later go on to say that the medical record should clearly identify the chief complaint or the reason for the encounter. The chief compliant is a required history component and must be included on every patient encounter in order to identify the medical necessity of the service.
The chief complaint should be the easiest part of the note. The CPT defines the chief complaint as “a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s words.” The chief complaint is the reason for the admission or consult and does not change during the course of the admission. For example, if the paint is admitted with shortness of breath, “shortness of breath” is the chief compliant that should be documented in the progress notes every day of the admission. If it resolves, “shortness of breath” is still the chief compliant and the interval history that day will describe the shortness of breath as “ resolved” or “ improved”. The chief compliant can be documented as a symptom like shortness of breath or a diagnosis like pneumonia. Each day in the progress notes, the chief complaint needs to be followed by an interval history that describes the complaint (using the 8 elements to describe the complaint as outlined in the CMS Guidelines) since the previous day’s documentation.
How often is the chief complaint totally omitted in a follow-up note? Or just as ghastly, it’s documented as “patient has no complaints” or “follow-up.” Sometimes there’s just a long list of negative ROS in place of a chief complaint. When an auditor cannot locate the chief complaint, he is left to guess why you are seeing the patient. Worse yet, when all that’s documented is “patient has no complaints,” the auditor assumes the patient is doing great and whatever brought him into the hospital has resolved (i.e., The patient should have gone home yesterday. Why are you still billing for services?).
It’s hard to convince an auditor, no matter how descriptive the assessment and plan is, that there is medical necessity for your services for the day if the patient doesn’t have a complaint. If the complaint isn’t documented, like anything else, the payer will assume there isn’t one. Failure to identify a chief complaint on every date of service can open you up to unnecessary denials. Remember to start each encounter with the chief complaint that will help support the medical necessity of your services for the day.
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