Hoping someone out there can help with this situation. Pt came into office, Dr performed pelvic exam, general exam and vitals. Then she said:
"Missed abortion-likely completed. POCs gently removed from os with decreased bleeding thereafter. Expected clinical course reviewed. She will f/u for weekly B-hcg until negative. POCs sent to path. Seems to be coping emotionally and has good family support. Reasons to seek medical attiona reviewed. All questions answered.
How would you code this?
"Missed abortion-likely completed. POCs gently removed from os with decreased bleeding thereafter. Expected clinical course reviewed. She will f/u for weekly B-hcg until negative. POCs sent to path. Seems to be coping emotionally and has good family support. Reasons to seek medical attiona reviewed. All questions answered.
How would you code this?