The documentation guidelines state that "the medical record must clearly reflect the chief complaint". If you can identify the reason for the visit, you have your chief complaint. Since the physician identified an additional problem oriented issue, this would suffice.
Preventative exams are not time based. The physician selects the appropriate service based on age and whether the patient is new or established. Just make sure that you separate the elements for the problem oriented complaint so that you're not using the same elements for both your PE and problem oriented E/M. The problem oriented E/M needs to be able to stand on its own.
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