Wiki New patient - HPI

[shruthi]

Need your quick suggestion.

This is for new patient,

Physical examination is comprehensive
Medical decision making is moderate

In history - HPI is EPF (only 3 elements are found)
ROS is complete
PFSH is complete.

So can we give the level 2 just because one element in HPI is missing ?
(because of 3 elements in HPI level will be 2, and if there was 4 elements in HPI then level would have been 4)

Thoughts?

 

[NeoCoder116]

That one HPI is all the difference

I would code down to the level 2. It can be audited and you will be dinged later for it.