Medicare Compliance & Reimbursement - 2009 Issue 29
E/M CODING: Hail to the Chief -- Complaint
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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.
Why This Topic Matters
Clear chief complaint documentation can affect audit outcomes and the defensibility of E/M history elements in physician records. The article helps readers understand the documentation issue at a high level before reviewing the full guidance.
What You Will Learn
- How chief complaint documentation is evaluated in E/M notes
- How the chief complaint relates to other history elements
- How Medicare-related documentation guidance addresses chief complaint placement
- How staff documentation and physician validation may be handled by a Medicare carrier
Who Should Read This
- Medical coders
- Clinical documentation improvement staff
- Physician office staff
- Audit and compliance reviewers
- Billing personnel
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