An established patient only needs two out of three components, so if her Exam and MDM meet or exceed the requirements for a level 4 visit then you don't need to worry about the HPI. She does need to document a chief complaint. Also, some doctors don't document nice and neat to make it easy for us to audit, many times you haave to read through the whole note to dig out what you need and your ROS may not be in the history where you want it. Since I haven't read the note I cannot really say much, just letting you know what I've seen over the years.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join