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Wiki What documentation needs to be in a Medical Note

Thread starter Brenda Crouch
Start date Jun 25, 2025

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Brenda Crouch

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Jun 25, 2025

I have been seeing medical notes at my job without a plan just labs the provider ordered. They do have CC and HPI. What is necessary for a coder to make sure that a medical note has in a primary care practice to be compliant in coding out the claim. Thank you.

Last edited: Jun 25, 2025

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