solocoder
Expert
On an established patient visit, if I am not counting the history toward the level, only the exam and MDM... does there have to be a chief complaint documented?
Here is a typical HPI for one of my doctors:
SUBJECTIVE: This 63-year-old male notes approximately 50% improvement compared to last visit of 04/19/11. He grades pain +2/10. He states the injection was helpful for a few days. Symptoms returned but then he did start to get somewhat better once again about 3 days ago. He states the strapping to the longitudinal medial arch did not help a great deal.
I'm saying "improvement in WHAT"? Do I need to have a talk with him about CC? Or are we OK without it?
Here is a typical HPI for one of my doctors:
SUBJECTIVE: This 63-year-old male notes approximately 50% improvement compared to last visit of 04/19/11. He grades pain +2/10. He states the injection was helpful for a few days. Symptoms returned but then he did start to get somewhat better once again about 3 days ago. He states the strapping to the longitudinal medial arch did not help a great deal.
I'm saying "improvement in WHAT"? Do I need to have a talk with him about CC? Or are we OK without it?