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Pilar10

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Green brook, NJ
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Doctor saw an established patient but he did not record the HPI or the ROS would i be able just to code the e/m based on the assessment and plan and previous HPI? Or would i just only bill for a vaccine he administered and not bill for the e/m. Please advise. Thank you all for your immediate response.
 
HPI is a required documentation element for all levels of office E&M codes. I would not bill an E&M without it.
 
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