You’re probably undercoding. Here are two sample office notes:
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.
ROS: Denies shortness of breath or heart palpitations.
EXAM: Vitals: temp 101.5, BP 140/80
Chest: rhonchi bibasilar, pain on deep inspiration
A/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
A/P: Chest pain. ECG and stress test ordered. Follow up scheduled.
They are both 99214′s. Code without fear.