Wiki level of history

[soprano]

This is all the physician wrote:

S:
1) How long to wear brace?
2) How long to use lidoderm patches?
3) Finished PT

Vitals: BP 131/91
Pulse: 71
Temp: 96.7

O:
+ Tinel's
+Phalen's

A/P:
R CTS
up to 8 weeks long term lidoderm ok but must have holiday
discussed visible signs of atrophy


Any thoughts on how many HPI elements this is? If there are any, what are they? Thank you in advance.

 

[soprano]

Hpi

Anyone?

I'm trying to figure out what, if any HPI elements are there in this note.

 

[purplescarf23]

I do not see any HPI elements. I also do not see a chief complaint which is a requirement to bill an e/m regardless what other elements you may or may not have. I would say unless the provider wants to addend this note I would not bill it. I'd give the provider the chance to but after a week or two I would no charge the visit.

Kelsey, CPC, CEMC