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I was doing a chart audit on a patients chart. I came across this chart.
CC-check up, review labs
HPI- pt is 91 yrs old, To update records as has blood drawn here per PCP in MD when visiting daughter who resides in this area. Was last seen in this clinic in 7/2016. A recent medial exam by another provider since last office visit PCP 4/2019.
No recent hospital or emergency department visit since last office visit.
I told the provider in the chart review that there is no CC or HPI so this claim is unbillable. He says there is a CC and HPI, but how can I count either? It doesn't tell me anything.
Tell me what you all think of this.
CC-check up, review labs
HPI- pt is 91 yrs old, To update records as has blood drawn here per PCP in MD when visiting daughter who resides in this area. Was last seen in this clinic in 7/2016. A recent medial exam by another provider since last office visit PCP 4/2019.
No recent hospital or emergency department visit since last office visit.
I told the provider in the chart review that there is no CC or HPI so this claim is unbillable. He says there is a CC and HPI, but how can I count either? It doesn't tell me anything.
Tell me what you all think of this.