{"id":441,"date":"2021-08-11T21:27:00","date_gmt":"2021-08-11T21:27:00","guid":{"rendered":"https:\/\/qa.apogeephysicians.com\/blog\/?p=441"},"modified":"2021-08-17T18:19:23","modified_gmt":"2021-08-17T18:19:23","slug":"general-principles-the-chief-complaint","status":"publish","type":"post","link":"https:\/\/qa.apogeephysicians.com\/blog\/2021\/08\/11\/general-principles-the-chief-complaint\/","title":{"rendered":"General Principles &#8211; The Chief Complaint"},"content":{"rendered":"\n<div class=\"wp-block-uagb-inline-notice uagb-inline_notice__outer-wrap uagb-dismissable uagb-inline_notice__align-left uagb-block-87629051\"><span class=\"uagb-notice-dismiss\"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewbox=\"0 0 512 512\"><path d=\"M464 32H48C21.5 32 0 53.5 0 80v352c0 26.5 21.5 48 48 48h416c26.5 0 48-21.5 48-48V80c0-26.5-21.5-48-48-48zm-83.6 290.5c4.8 4.8 4.8 12.6 0 17.4l-40.5 40.5c-4.8 4.8-12.6 4.8-17.4 0L256 313.3l-66.5 67.1c-4.8 4.8-12.6 4.8-17.4 0l-40.5-40.5c-4.8-4.8-4.8-12.6 0-17.4l67.1-66.5-67.1-66.5c-4.8-4.8-4.8-12.6 0-17.4l40.5-40.5c4.8-4.8 12.6-4.8 17.4 0l66.5 67.1 66.5-67.1c4.8-4.8 12.6-4.8 17.4 0l40.5 40.5c4.8 4.8 4.8 12.6 0 17.4L313.3 256l67.1 66.5z\"><\/path><\/svg><\/span><p class=\"uagb-notice-title\">Disclaimer<\/p><div class=\"uagb-notice-text\"><p>This article and the related comments are for educational and discussion purposes. They do not establish the standard of care in every patient\u2019s situation. In each patient\u2019s 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. <\/p><\/div><\/div>\n\n\n\n<p>The CMS 1995 Documentation Guidelines for E&amp;M Services begins with a list of general principles of medical record documentation. Number two on the list behind \u201cthe medical record should be complete and legible\u201d is \u201cthe documentation of each patient encounter should include a reason for the encounter\u201d (chief complaint). The Guidelines later go on to say that the medical record should&nbsp;<strong>clearly&nbsp;<\/strong>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.&nbsp;<\/p>\n\n\n\n<p>The chief complaint should be the easiest part of the note. The CPT defines the chief complaint as \u201ca concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the&nbsp;<strong>reason for the encounter<\/strong>, usually stated in the patient\u2019s words.\u201d 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, \u201cshortness of breath\u201d is the chief compliant that should be documented in the progress notes every day of the admission. If it resolves, \u201cshortness of breath\u201d is still the chief compliant and the interval history that day will describe the shortness of breath as \u201c resolved\u201d or \u201c improved\u201d. 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\u2019s documentation.&nbsp;<\/p>\n\n\n\n<p>How often is the chief complaint totally omitted in a follow-up note? Or just as ghastly, it\u2019s documented as \u201cpatient has no complaints\u201d or \u201cfollow-up.\u201d Sometimes there\u2019s 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\u2019s documented is \u201cpatient has no complaints,\u201d 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?).&nbsp;<\/p>\n\n\n\n<p>It\u2019s 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\u2019t have a complaint. If the complaint isn\u2019t documented, like anything else, the payer will assume there isn\u2019t 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.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>The CMS 1995 Documentation Guidelines for E&amp;M Services begins with a list of general principles of medical record documentation. Number two on the list behind \u201cthe medical record should be complete and legible\u201d is \u201cthe documentation of each patient encounter should include a reason for the encounter\u201d (chief complaint). The Guidelines later go on to &#8230; <a title=\"General Principles &#8211; The Chief Complaint\" class=\"read-more\" href=\"https:\/\/qa.apogeephysicians.com\/blog\/2021\/08\/11\/general-principles-the-chief-complaint\/\" aria-label=\"More on General Principles &#8211; The Chief Complaint\">Read more<\/a><\/p>\n","protected":false},"author":6,"featured_media":442,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"advgb_blocks_editor_width":"","advgb_blocks_columns_visual_guide":""},"categories":[7],"tags":[],"author_meta":{"display_name":"Amy Maverick, MD","author_link":"https:\/\/qa.apogeephysicians.com\/blog\/author\/amy-maverick\/"},"featured_img":"https:\/\/qa.apogeephysicians.com\/blog\/wp-content\/uploads\/2021\/08\/Compliance2-300x188.jpeg","yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v17.0 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>General Principles - The Chief Complaint &mdash; Apogee Insights<\/title>\n<link rel=\"canonical\" href=\"https:\/\/qa.apogeephysicians.com\/blog\/2021\/08\/11\/general-principles-the-chief-complaint\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"General Principles - The Chief Complaint &mdash; Apogee Insights\" \/>\n<meta property=\"og:description\" content=\"The CMS 1995 Documentation Guidelines for E&amp;M Services begins with a list of general principles of medical record documentation. Number two on the list behind \u201cthe medical record should be complete and legible\u201d is \u201cthe documentation of each patient encounter should include a reason for the encounter\u201d (chief complaint). The Guidelines later go on to ... 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