You’re probably undercoding. Here are two sample office notes:
CC: Cough
HPI: 75-year-old male with productive cough for five days, worse at night. Patient also has fever and chest pain. Patient using cough syrup without improvement.
PH: Non-smoker.
ROS: Denies shortness of breath or heart palpitations.
EXAM: Vitals: temp 101.5, BP 140/80
ENT: negative
Neck: negative
Chest: rhonchi bibasilar, pain on deep inspiration
CV: negative
Abd: negativeA/P: Acute bronchitis. Rx: Azithromycin, expectorant. Follow up as needed.
* * * * * * * * * *CC: Chest pain
HPI: 58-year-old female with intermittent, sharp chest pain over two weeks. Episodes last 10 minutes at a time. Pain occurs at rest.
PH: Non-smoker, no family history of cardiovascular problems.
ROS: No shortness of breath. No reflux.
EXAM: Vitals: BP 120/80, P 65
Lungs: clear to auscultation
CV: normalA/P: Chest pain. ECG and stress test ordered. Follow up scheduled.
They are both 99214’s. Code without fear.
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