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Need help with HPI and MDM

  1. Cool Need help with HPI and MDM
    Medical Coding Books
    I am working on a clinic follow up visit. My physician states c/o mid back pain-not as bad this week, no acute or chronic injury, never had befroe. When I get to the MDM he only lists dx. for HTN & Dyslipidema. No tests are ordered and he doesn't mention the back pain anymore What should I use for a cc? The back pain or a follow up or not billable?

  2. #2
    I would give this back to the MD and query him to clarify the pdx
    CC is back pain
    Duration this week
    ROS no acute or chronic injury
    Did he do an exam?
    This is a poorly documented record
    Robin Ingalls-Fitzgerald CCS, CPC, FCS, CEMC, CEDC

  3. Default
    Yes he did a exam but does not address the musc. system at all.

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