Help with E/M HPI

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Please help!! I have a chart where the Dr. didn't put what the c/o was. He reviewed an MRI with the patient and then at the bottom is an office note from a previous office visit with another Dr. I am new to E/M coding and haven't seen anything like this before. :confused:


Never mind. The Dr. put the HPI at the bottom of the OV note instead of the top. Very confusing. Thanks!
 
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Jagadish

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It is not necessry that the HPI documentation should done under a specific indentation in the record. You can take the HPI information documented anywhere.
 
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