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Wiki Need help with HPI and MDM

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LAH1964

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I am working on a clinic follow up visit. My physician states c/o mid back pain-not as bad this week, no acute or chronic injury, never had befroe. When I get to the MDM he only lists dx. for HTN & Dyslipidema. No tests are ordered and he doesn't mention the back pain anymore What should I use for a cc? The back pain or a follow up or not billable?
 
I would give this back to the MD and query him to clarify the pdx
CC is back pain
Duration this week
ROS no acute or chronic injury
Did he do an exam?
This is a poorly documented record
Robin Ingalls-Fitzgerald CCS, CPC, FCS, CEMC, CEDC
 
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