PE vs OV

DLT

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Reading, PA
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I am having an issue with our providers not being clear on their electronic documentation. To give a brief understanding of what I am experiencing - The pt schedules for a PE and CC is Health Maintanence with bladder issues and back issues. The provider goes through the entire visit discussing PFSH, ROS, Physicial Exam and renews medications for HTN, Hypercholesterol, etc - Then the dx code deals with bladder, htn - there is no dx for PE. should this visit just be a OV or can I add the 25 mod to an office visit and still bill for the PE?
 
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