Coding

samyjm13

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Meridian, ID
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A new patient comes into the clinic for a follow up from being in ER for a miscarry, the documentation has a HPI, PFSH, ROS, but examination was deferred. Would I code the lowest level or query the doctor on how much time was spent with the patient?
The doctor requested her to come back in 3 weeks for an annual.
Thanks
 
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