July 09, 2015
When an auditor is reviewing a medical record, the first focus of review is the chief complaint (CC). While the CC is not associated with any down-coding penalties it is the driving force behind the medical necessity of the E&M encounter. Documentation Guidelines state that the CC should be a clear concise statement of why the patient required a face-to-face encounter with the provide. For this reason, a CC such as patient here for follow up, or patient here to establish care do not provide the true reason the patient encounter occurred. The problem for which they are following up on would be the most appropriate CC as it truly identifies the reason for the encounter. Guidelines also indicate that the CC should be recorded in the patient's own words, but let's face it: we would end up with a CC such as I am not sure, he told me to come back. Looking at this requirement from a medical necessity stand point, it would seem that the spirit of that guideline is in keeping the CC relevant to the patient's complaint(s) and not diagnose them in the chief compliant (i.e., Patient complains of urinary frequency and burning as opposed to Patient presents for UTI). Set up your encounter to display the medical complexity involved with the needed patient care in order to ensure medical necessity is met along with the documentation guidelines by appropriately documenting the CC.
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