I wouldn't allow it. The DG's state...
The documentation of each patient encounter should include:
â€¢ reason for the encounter and relevant history, physical examination
findings and prior diagnostic test results;
!DG: The medical record should clearly reflect the chief complaint.
Not providing the chief complaint creates an issue for medical necessity. It would be difficult to justify a detailed exam with moderate MDM (your example) with the absence of a CC. The CC paints a picture for the reason of the visit and illustrates the complexity.
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