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Chief complaint or history of present illness?
Question: I know that every visit needs to have a chief complaint, but I was recently told that information in the chief complaint can’t be used in the HPI. Is this true?
Answer: It is the very rare regulator or reviewer that would take that approach. The rule is that there needs to be a chief complaint, and one CMS definition is: the “CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words.”
The HPI on the other hand is “a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.”
If your chief complaint were knee pain, it is certainly permissible to describe the duration, severity, etc., and the knee itself qualifies as the location of the problem.
Talk of "double dipping" is usually about information shared between the HPI and the ROS, not the HPI and the CC.
Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at email@example.com or firstname.lastname@example.org.
This question originally appeared in the November 2010 issue of Physicians Practice.