For a subsequent hospital visit you need only 2 out of 3 key elements: History & Exam / History & MDM / Exam & MDM
I would give credit for the CC from the copied HPI ... subdural hemorrhage, headaches, blurry vision
"No complaints" is totally inadequate for an interval history, however. "No headaches, vision clear" would be a different story, as it would tell me WHY the patient is being evaluated.
It is still possible that the exam and MDM are enough for the level of service. So I can't say from the limited info provided whether this note is billable or not.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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