How would you handle this coding situation for the CC and parts of HPI?
This is what the physician documented,
History of Present Illness:
1. Follow up, review apt
(name here) is doing well generally–summary of his issues are below.
I don’t feel this states a Chief Complaint and there are no elements for the HPI. I don’t think I should query the provider asking for the chief complaint and HPI because this can create a different e/m level after the physician has already signed the note and I think this encroaches on leading the provider. In the assessment/plan the physician does state what they went over.
Would you determine this as non-billable? Looking for advice on what you would do. Thank you