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CHIEF COMPLAINT
 

 
Many physicians don't realize that a chief complaint is required for every type of encounter.  It may be a somatic complaint from the patient (e.g., “headache” or “shortness of breath”) or it may be a statement from the physician which defines the purpose for the visit (e.g., “follow-up for hypertension”) . 

E/M University Coding Tip : Every single type of encounter from an initial consultation to an office follow-up visit or even a hospital progress note must have a chief complaint recorded in the medical record.  Payment for services is sometimes denied simply because the physician did not include a chief complaint in the note.

E/M University Coding Tip : The Chief Complaint may be recorded separately or may be documented within the HPI.
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