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I am coding E/M for a pulmonology office, mainly hospital critical care, consults, and progress notes. Doctor B never, EVER has a separate chief complaint documented. Doctor A,who runs the practice, hired me to look for errors and help fix them to keep from being audited. How do I approach this...
Does the chief complaint need to be separate from the HPI? There has been information out there that says that the chief complaint can listed under its own header or as the first sentence of the HPI (as long as it is clear). At my facility, many providers are split when doing this and I am...