maine4me
Guru
Okay, I am currently auditing a note for an new patient visit from our Infectious Disease Practice. When I look at the note I do not see anything that would be considered medical decision making, no assessment or plan. If this element has been omitted from the note is the visit billable?
Also, for history there are only 3 elements of HPI, 4 systems for review of systems, and 1 system in the exam.
Also, for history there are only 3 elements of HPI, 4 systems for review of systems, and 1 system in the exam.