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ktden

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Dr. list no cc: HPI reads no new complaints, no headache, no dyspnea, no urinary symtoms, missed last apt.
ROS states intake records indicates "problems" hypertension uncontrolled", can this be used as CC.
This documentation is taken by someone other than the phys.

Thanks in advance.
 
No complaint

If there's no complaint I would assume it is a preventive visit.

If it's an established patient you might still be able to code with just exam and MDM. But EVERY note should have a chief complaint (even if that is "F/U for HTN")

If something is listed in the ROS you cannot use that as a chief complaint. No idea when that problem occurred.

Also the HPI (including chief complaint) must be taken by the physician. ROS and PFSH can be taken by anyone.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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