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Primary Care Coding Alert

Primary Care Coding:

Rely On Discrete Documentation for Specific Encounter

Published on Thu Nov 20, 2025

Question: One of the primary care physicians (PCPs) I work for documented a visit: a 78-year-old patient with several differential diagnoses who presented for diarrhea, which they have been experiencing for seven days, along with dizziness for five months. The provider wrote that they performed a physical exam but did not have the ability to run labs in-house and so [...]
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