1. For Duration under HPI I was instructed that I need an exact date of onset. I now have an auditor saying "Sept of last year" and "Pathology on 12/15/16" are acceptable to use under duration. Please confirm.
2. For Severity under HPI I was instructed to use anything with a scale of pain or stage / grade of disease, the auditor is using "Metastatic" and "increasing pain". Which is correct?
3. What details are needed to include all 4 extremities under Physical exam?
4. In order to obtain points for "Independent review" under MDM, reviewed/ordered data are things like "We looked at her MRI scans and you can clearly see the recurrence" or "We looked at the films together and I mapped out the changes for him" considered acceptable proof of Independent review?
5. For MDM, specifically for a follow up visit, how does one determine the complexity if they are not returning for their "Chief complaint"? Should it be just for today’s visit, or include the patient’s previous disease?