Brush up on ‘chief complaint’ documentation

Article Overview

This article reviews chief complaint documentation in the context of evaluation and management (E/M) coding. It is aimed at coders, billers, auditors, and clinical staff who document visit reasons in the medical record, and it discusses general guidance from the 1995 and 1997 E/M documentation guidelines, including how chief complaint information may appear in the history or be reflected within the history of present illness. The piece focuses on documentation quality, common pitfalls with generic visit reasons, and the role of staff education in supporting compliant records.