E/M Weekly Tip: Chief Complaint

A chief complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return or other factor that is the reason for the patient encounter. A CC is required for all levels of service. The extent of the information gathered for the CC and history component is dependent upon clinical judgment and the nature of the presenting problem. The documentation must clearly reflect the CC.

Resource: Evaluation and Management Services (PDF, 3.09 MB).