no HPI

If the CC and ROS are documented but an HPI is not, how do I code the history for a regular sick/follow up visit?

Thank you!

re: no HPI

You can pull HPI from the ROS. If nothing else then you should at least be able to get signs and symptoms. That will drop the Hx to problem focused but for an established patient you only need 2/3 to get your level.

re: no HPI

Thank you; your response was very helpful. I do have documentation though for a patient whose CC and HPI are something like "patient here for follow up" and "28 year old male here for suture removal". There is no ROS. How do I code this history?