Wiki Re-record a ROS and/or a PFSH

KoBee

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I have a provider who is being audited for billing 99214 constantly

I'm having trouble understanding if he gets credit in his HPI for ROS/PFSH stating "unchanged".. he seems to do this for every encounter especially when following up. Can anyone help please?

Example of one of the documentations:



Chief Complaint
Patient presents with​
•​
Migraine​
follow up


HPI
Pt with McCune-Albright syn and migraine without aura 2 x a week much improved with neurontin 600 mg po bid


ROS
The ros, pmh, fh, sh, immunizations and allergies are unchanged from the visit of 12/5/2018


Objective:

Physical Exam 


Constitutional: She appears well-developed and well-nourished.


HENT:


Head: Normocephalic and atraumatic.


Eyes: EOM are normal. Pupils are equal, round, and reactive to light.


Cardiovascular: Normal rate, regular rhythm and normal heart sounds.


No murmur heard.


Pulmonary/Chest: Effort normal.


Abdominal: Soft.
Musculoskeletal: Normal range of motion.
Neurological: She is alert.


Skin: Skin is warm.
2 large cafe au lait spots 
Psychiatric: She has a normal mood and affect.


 BP 120/80 mmHg | Pulse 89 | Temp(Src) 98.1 °F (36.7 °C) (Oral) | Ht 5' 3.39" (1.61 m) | Wt 206 lb (93.441 kg) | BMI 36.05 kg/m2 | LMP 07/25/2017


Assessment:

Mcune Albright syn

Migraine without aura


Plan:



rtc in 1 months
neurontin 300 mg caps 2 am and 2 at lunch and 2 at night
 
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