If she came in for a problem and the notes don't indicate that she had an 'annual exam' (or well check, etc.), then advise the patient that the records don't indicate that she had a preventive exam, so she would need to speak with the doctor to dispute his documentation. Whatever you do, DO NOT change the code just because the patient has asked you to. She's not the one that will get in trouble over it. Hope that helps!
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