tci Part B Insider - 2009 Issue 29

E/M CODING: Hail to the Chief -- Complaint

Chief complaint need not be at the very top of the note, but the physician must state it clearly. Getting dinged on audits because you don't have a chief complaint listed at the top of your physician's documentation? Don't give up until you check the entire note. Although you'll benefit from a chief complaint documented clearly at the beginning of the note, Medicare doesn't require that you list it at the top. "The chief complaint should be clearly illustrated," says Suzan Berman (Hvizdash), CPC, CEMC, CEDC, senior manager of coding and compliance in the departments of surgery and...

To read the full article, sign in and subscribe to tci Part B Insider.

Thank you for choosing Find-A-Code, please Sign In to remove ads.