tci E/M Coding Alert - 2019 Issue 3

Reader Question: Be Specific With Follow-Up Chief Complaints

Question: Our otolaryngologist lists the chief complaint (CC) for all follow-up visits using just “f/u” — we have never had an issue collecting payment, but our coder is concerned that this isn’t compliant. Can you advise? Illinois Subscriber Answer: The chief complaint is not thorough enough, and if the physician writes the same thing on every record, he could even be at risk of accusations of “cloned notes” or, more importantly, providing medically unnecessary services. The chief complaint establishes the medical necessity for the encounter. First and foremost, avoid “follow-up” as a catch-all complaint. All...

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