I'm a little confused, the highest level you can get for the HPI is extended (4 or more elements). I'm assuming you meant you need get a detailed history and therefore you need an extended HPI.
I keep getting a brief history. Is the chief complaint pain & being tired? In which case I think you could use "had to lay down" as a severity stmt. The context is "s/p surgery" but that's all I get.
maybe duraton of a few hours because we know the surgery was earlier that same day??
If you can't reach a detailed history, can't you drop the E/M to 99212 or 99213?
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