Objective:

The article explains how the chief complaint supports coding and auditing by documenting the patient's reason for an encounter and helping establish medical necessity.

Approach:

• Definition and purpose: The chief complaint (CC) is a short statement of the patient's reason for the encounter, usually in the patient's own words. It helps establish the context for evaluating medical necessity.
• Purpose of the examination: For an eye examination, coverage depends on its purpose rather than the diagnosis ultimately found. Discovering pathology during an examination does not, by itself, make an examination that began as routine covered as a medical service.
• Documentation during the visit: If a patient reports a relevant complaint to the doctor that was not initially recorded, update or clarify the CC and relevant history. For follow-ups, document the condition being monitored and the patient's current status; a new symptom is not required.
• Diagnostic testing: The CC and history begin the medical-necessity record but need not independently justify every test. Examination findings, known diagnoses, prior testing, clinical changes, and the physician's assessment may further explain why a test was ordered.

Key Findings:

• A scheduled routine examination does not become a medical encounter solely because a condition is discovered during it.
• A new symptom reported during the encounter should be captured in the record, along with relevant history.
• A follow-up can be medically necessary without a new symptom; documentation can identify the condition being monitored and the patient's status.
• Auditing red flags include generic or repeated CCs, a CC that conflicts with the primary diagnosis, and extensive testing with little documented rationale. These prompt review but do not alone establish incorrect coding.

Interpretation:

The article presents the CC as the starting point for documenting why the patient came in that day and for tracing the medical necessity of services. It cautions against substituting the appointment schedule or a diagnosis discovered later for the original reason for the encounter.

Limitations:

• The article is a practice-focused discussion and does not report original research or quantify the effects of documentation practices.

Conclusion:

Document the patient's reason for the visit accurately, updating it when relevant information emerges during the encounter.

Sources:

• Centers for Medicare & Medicaid Services. Evaluation and management services. Medicare Learning Network, MLN006764.
• Centers for Medicare & Medicaid Services. Medicare claims processing manual: coverage of services rendered by an ophthalmologist. Transmittal 1802.
• American Academy of Ophthalmology. Is the chief complaint important?