If there's no complaint I would assume it is a preventive visit.
If it's an established patient you might still be able to code with just exam and MDM. But EVERY note should have a chief complaint (even if that is "F/U for HTN")
If something is listed in the ROS you cannot use that as a chief complaint. No idea when that problem occurred.
Also the HPI (including chief complaint) must be taken by the physician. ROS and PFSH can be taken by anyone.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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