tci Medicare Compliance & Reimbursement - 2006 Issue 33

CODING: Avoid Vague Phrases Like 'Patient Feeling Better' As Chief Complaint

Hail to the chief complaint--even if it's at the end of the note.Getting dinged on audits because you don't have a chief complaint listed at the top of your physician's note? Don't give up until you check the "assessment" section of your note.The problem: Official guidelines say that the chief complaint, the main reason for the patient's visit, must appear at the top of the physician's note or in the history of present illness (HPI) section, says Jim Collins, president of The Cardiology Coalition in Matthews, NC. The solution: "In the real world, the reason for...

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