5 Key Takeaways

• 1

  The chief complaint states the patient's reason for the encounter and helps document the sign, symptom, or concern supporting medical necessity.

• 2

  For eye examinations, CMS says coverage depends on the examination's purpose, so pathology discovered during a routine exam does not alone make it a covered medical service.

• 3

  When a patient reports a complaint to the doctor that was not initially recorded, update the chief complaint and relevant history to reflect the conversation.

• 4

  A medical follow-up can be necessary without a new symptom; document the condition being monitored and the patient's current status.

• 5

  The chief complaint and history begin the medical-necessity record, while examination findings, diagnoses, prior testing, and the assessment may support diagnostic testing.