E/M CODING: Hail to the Chief -- Complaint

Article Overview

This short E/M coding article discusses how the chief complaint should be documented in physician records, including where it may appear within the note and how it relates to Medicare documentation guidance. It is aimed at coders, auditors, and clinical documentation staff who review E/M histories and want to understand the documentation standard without over-reading the placement of the complaint at the top of the note. The article also touches on how staff involvement and physician validation are handled by a Medicare carrier.