"no change"

no change

No change from what? What is the purpose of the visit? What is the chief complaint?. You would need more information to code this visit.
I agree. The diagnosis, rationale, or impression for the visit should be on the note. Correct me if I'm wrong but I believe that documenting the diagnosis or rationale is included in the documentation guidelines for E/M. Each progress note should stand on it's own. The diagnoses on the bill or claim form should be supported by what is in the progress note.
Great, that's what I was thinking...the note should stand on it's own. The auditor shouldn't have to search the rest of the chart to figure out the Dx. :rolleyes: