Each time you meet with a patient, you should document a chief complaint (CC). CPT defines the CC as “A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s words.” Simply stated, the chief complaint is a description of why the patient is presenting for healthcare services.
An easily identifiable chief complaint is the first step in establishing medical necessity for services rendered. The 1995 and 1997 Documentation Guidelinesfor Evaluation and Management (E/M) Services specifically require, “The medical record should clearly reflect the chief complaint.” If the patient record does not reflect a chief complaint, the service is either:
- A preventive service; or
The treating/billing provider should personally verify the patient’s chief complaint. For example, a patient may be embarrassed, or have other reasons not to share the “real” CC with ancillary staff, or to record it on a patient questionnaire or intake form. If the patient is returning for a follow up, the provider must likewise document the reason for the follow up.
Do not confuse the CC with the history of present illness (HPI);they are separate elements. The CC is the reason why the patient is there. The HPI details the CC. Although the CC directs the line of questioning in the HPI and the Review of Systems (ROS), the extent of history obtained should not be more than is medically necessary to evaluate the patient. According to the CMS Evaluation and Management Services Guide, “The CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of present illness.”
Preventive medicine services (CPT® 99381-99387) do not require a chief complaint. Because a preventive medicine service is not problem-oriented, you should not diagnose it, as such. Instead, match preventive medicine codes with an appropriate ICD-9-CM code to support the services provided (e.g., V70.0 Routine general medical examination at a health care facility for adults, V72.31 Routine gynecological examination for gynecologic exams and V20.2 Routine infant or child health check for well-child care). You may use additional special screening codes (V73.0-V82.9), as appropriate.
Some providers may require a “get acquainted” visit with new patients, which are provided absent a chief complaint from the patient. These visits are not considered to be medically necessary by either private or government payers. Unless your policy is to offer these services at no charge, patients should be explicitly informed when they schedule the appointment that they will be financially responsible for the entire cost of the visit.