Coding & Reimbursement

Explaining, defining the chief complaint

Taking a medical history starts with obtaining the chief complaint. For reimbursement, coverage by a medical or vision plan primarily depends on the chief complaint.

Q. What is a chief complaint?

A. The chief complaint is described in the 1997 CMS Documentation Guidelines for Evaluation and Management (E/M) Services as “…a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s words.” It is the answer to the question, “Why are you here?” From a clinical perspective, the chief complaint helps set the stage for the rest of the eye exam. From a reimbursement perspective, it determines who is responsible for the claim — medical insurance, vision insurance or the patient.

Q. Who obtains the chief complaint?

A. It can be obtained by any appropriately trained member of the staff. This is an important point that highlights a key difference between the chief complaint and the history of present illness (HPI), which must be performed by the physician or other health care provider to count as part of an E/M service. While a medical assistant, ophthalmic technician or scribe can annotate in the medical record what the physician dictates for the HPI, these physician extenders cannot originate the HPI, only the chief complaint.

It’s an easy matter to begin with an open-ended question such as “How can we help you today?” and listen to the response. You don’t have to record every word the patient says; it’s sufficient to capture just the salient points. To no one’s great surprise, the physician may gather additional information from the patient about the reason for the visit and supplement the technician’s brief note. (Yes, patients often tell a doctor something they didn’t tell staff!)

Q. How does the chief complaint affect insurance coverage?

A. Health insurance doesn’t pay for all health care; there are exclusions from coverage. By law, Medicare excludes routine physical checkups for prevention or screening (other than those explicitly covered by law as noted in section 42 CFR 411.15(a)(1)).

Medicare does not pay for routine vision exams “… for the purpose of prescribing, fitting, or changing eyeglasses or contact lenses for refractive errors.” Medicare beneficiaries may choose to have routine or annual eye exams; however, the beneficiary would be responsible for payment. So, a patient who says, “My eyeglasses aren’t satisfactory, and I want to get new ones” is subject to this Medicare exclusion.

According to CMS, “Coverage depends on the purpose of the eye examination rather than on the ultimate diagnosis of the patient’s condition. If the beneficiary has a complaint or symptoms of an eye disease or injury, the examination is covered even though only eyeglasses were prescribed. However, if the beneficiary desires only an eye examination with no specific complaint, the expenses for the examination will not be covered, even though, as a result of the examination, the doctor discovers a pathological condition. [Pub. 100-02, Ch. 16 §90.]”1

Medicare does cover an eye exam for a patient who returns for continuing care of a chronic medical condition without any subjective complaint. Medicare’s routine physical checkup exclusion does not apply in this instance; the policy states, “The exclusions do not apply to physicians’ services (and services incident to a physicians’ service) performed in conjunction with eye disease, as for example, glaucoma or cataracts”.2

The medical assistant or technician should make an appropriate note such as, “Here for follow-up to re-evaluate glaucoma per Dr. Smith.”

Remember, too, that a chart is not necessarily completed from top to bottom in neat chronological order. The patient may mention symptoms at any time throughout the exam; the new information can be added to the complaint. For example, consider a patient scheduled for a recheck of dry eye syndrome who, partway through the exam, mentions a sudden onset of floaters over the past few days. The additional complaint probably warrants a dilated fundus exam (DFE). Without the supplemental complaint, a DFE is difficult to justify for dry eye syndrome alone.

Sometimes the patient remembers a complaint after being prompted later in the exam. As an illustration, you observe a new macular pucker in an established patient whose sole request is for updated reading glasses. It’s reasonable for the ophthalmologist or optometrist to ask if the patient has noticed while reading small print increased difficulty with distortion as suggested by the presence of the macular pucker. In response, the surprised patient affirms that is the case, and the doctor appends another phrase to the chief complaint that more completely describes the situation, rendering the office visit covered for a medical condition. If the chief complaint only states, “Patient desires new reading glasses,” then the Medicare exclusion applies. OM


  1. CCH Medicare Explained, 2012, ¶619. Wolters Kluwer Law & Business. CCH Incorporated; 1 edition (February 13, 2012).
  2. CMS. Medicare Benefit Policy Manual. Chapter 16 §90. Routine Services and Appliances. . Accessed Nov. 7, 2017.