BC Advantage - 2016 Issue 8

Chief Complaint

What do you do when you come across an E&M encounter that has no chief complaint? Do you deem the encounter non-billable?For years, I have heard it said that EVERY encounter MUST have a chief complaint, bus is that really what documentation guidelines have to say? The only guidance we have on the chief complaint in either 1995 or 1997 Documentation Guidelines is this:"The Chief Complaint is a Concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. DG: The medical record should clearly reflect the...

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