Documentation: Chief – Complaint Must Be Stated Clearly

Documentation: Chief Complaint Must Be Stated Clearly

Getting dinged on audits because you do not have a chief complaint listed at the tip of your physician's documentation? Do not give up until you check the entire note.

Even though you will benefit from a chief complaint documented clearly at the start of the note, Medicare does not require that you list it at the top. The chief complaint should be illustrated clearly.

Listing it amongst the assessment might not give you the clearest picture. There might be other issues that came out in the visit (or other conditions the clinician is worried about as they relate to the chief complaint or the possible treatment options), but then they might not be the exact complaint."

The 1995 and 1997 CMS E/M documentation guidelines indicate that the chief complaint, review of systems, and the past family social history may be listed as separate elements of history or they may be included in the narrative of the history of the present illness (HPI). As a result, the chief complaint cannot just be anywhere on the record. "It must either be listed separately or in the HPI."

Key: The guidelines do not come out and say 'it must be at the top of the note,' however the guidelines are very clear that the chief complaint should not be implied but stated clearly.

What to do: In order to avoid having to dig into the assessment section of the physician's note, urge your gastroenterologist to write "c/c" at the top of the visit notes. Post this, the gastroenterologist should write a word or two explaining why the patient needs to be seen by a doctor. The gastroenterologist could just write, "follow-up for ulcer," "follow-up for gastritis complicated by MAC," or "follow-up for chronic pancreatitis and nausea."

Encourage your gastroenterologist not to write vague statements like 'feeling better', 'feels unwell', 'much better', 'comfortable', or 'resting quietly' as the chief complaint. Who can record it: Medicare carriers differ regarding which staff members can document the chief complaint. For example, WPS Medicare, the Part B payer in four states notes that the 1995 and 1997 Documentation Guidelines don't address who can record the chief complaint (CC). WPS Medicare will allow the chief complaint to be recorded by ancilliary staff. But then the physician must validate the CC in the documentation."

Remember: Most payers need the physician (or billing provider) to document the CC.

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