Chief Complaint

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I am going back-and-forth and then back-and-forth again on this. Would you
count the following statement as a chief complaint?

"....established patient presents for medical. Plan: vit. D, a.m. protein,
adaptenal."

Until I get to the end of the note I can't say for sure why the patient is
there.

Would you deny this?

Thanks,
Rhonda

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I am going back-and-forth and then back-and-forth again on t=
his.=C2=A0 Would you count the following statement as a chief complaint?

"....established patient presents for medical.=C2=A0 Pl=
an: vit. D, a.m. protein, adaptenal."

Until I get to the end of the note I can't say for sure =
why the patient is there.=C2=A0

Would you deny this?

Thanks,

Rhonda

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Comments

  • I would deny this; why is the patient getting vit d?

  • edited May 2017
    As long as you can discern somewhere in the note that it was a medically necessary visit, it is billable. The chief complaint does not have to be at the "beginning" of the note.

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