The patient came for HPI-IPPE without mentioning any separate CC,but the provider document in the ROS;positive for shoulder pain;WITH the
General Examination
MUSCULOSKELETAL: pain reproduced with internal rotation of left shoulder. tenderness with palpation of AC joint. no swelling or discoloration noted. normal strength.
ASSESMENT:
ROUTINE MEDICAL EXAM - V70.0 (Primary)
VACCIN FOR INFLUENZA - V04.81
Joint Effusion NOS
Start Naprosyn Tablet, 500 mg, Orally, 60, 1 tablet, Twice a day, 30 day(s), Refills 1
QUESTION?
Can i add a NEW SICK VISIT= 99201-99205 (which needs complete 3 elements of HPI;PE/MDM) since I don't have CC mentioned in the HPI to support the elements needed for a NEW PATIENT?
Thank you.