Documentation & Chief Complaint: Are You Missing Something

If you're getting dinged on audits because you do not have a chief complaint listed at the top of your physician's documentation, do not give up until you have a look at the entire note.

Even though you'll benefit from a chief complaint documented clearly at the start of the note, Medicare does not require that you list it at the top. The chief complaint should be illustrated clearly.

Listing it amongst the assessment might not give you the brightest picture. There might be other issues that came out in the visit (or other conditions the clinician is concerned about as they relate to the chief complaint or the possible treatment options), however they might not be the exact complaint.

The 1995 and 1997 CMS Evaluation/Management documentation guidelines point to the fact that the chief complaint, review of systems(ROS), and the past family social history may be listed as separate elements of history, or for that matter they may be included in the narrative of the history of present illness (HPI). As such, the chief complaint cannot just be anywhere on the record. It must be listed separately or in the HPI.

Key: The guidelines do not come out and say 'it must be at the top of the note,'; however the guidelines are very clear that the chief complaint shouldn't be implied but stated clearly.

What can be done: In order to avoid having to dig into the assessment section of the physician's note, urge your gastroenterologist to write "c/c" at the top of the visit notes. Post this, the gastroenterologist should write a word or two telling why the patient needs to be seen by a physician. The gastroenterologist could simply write "follow up for ulcer," "follow-up for gastritis complicated by MAC," or "follow-up for chronic pancreatitis and nausea."

Urge your gastroenterologist not to write vague statements like 'feeling better', 'feels well', 'much better', 'comfortable', or 'resting quietly' as the chief complaint. Who can record it: Medicare carriers differ regarding which staff members can document the chief complaint. For example, WPS Medicare, the Part B payer in four states points out that "the 1995 and 1997 Documentation Guidelines do not address who can record the chief complaint [CC]. WPS Medicare will allow the chief complaint to be recorded by ancillary staff.

Remember: Most other payers need the physician (or billing provider) to document the CC.

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