tci E/M Coding Alert - 2019 Issue Q4

Reader Question: Read Between the Lines to Locate Hidden Complaints

Question: We know we can’t report an E/M code without a chief complaint, but sometimes we have trouble finding one in our optometrist’s notes. Is there a formula for this? Mississippi Subscriber Answer: The chief complaint should be clearly illustrated somewhere in the notes, even though it doesn’t have to be at the top of the report. To avoid having to dig into the assessment section of the doctor’s note, encourage your doctor to write “c/c” at the top of the visit notes. After this, the doctor should write a word or two explaining...

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