Chief Complaint

March 17th, 2015 - Codapedia Editor
Categories:   Audits/Auditing   Coding  
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The guidelines go on to read, "The medical record should clearly reflect the chief complaint." This leaves physicians to ask the question, does the chief complaint need to be listed separately from the history of the present illness or the rest of the rest of the history?

The guidelines also say:

!DG: The CC, ROS and PFSH may be listed as separate elements of history, or theymay be included in the description of the history of the present illness.

That is, a physician or other health care professional who is billing for evaluation and management services, may include the reason for the visit, or the chief complaint, within the history of the present illness. Sometimes the chief complaint is very specific. "Patient reports that they have a four-week history of abdominal pain." Sometimes the reason for the visit may be less specific such as, "The patient is here for follow-up of their chronic medical problem." That is permitted as long as the remainder of the history of the present illness describes the problem that the patient has presented to the physician.

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