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2016;48:e215

Teubner BJ, Garretson JT, Hwang Y, Cole PA, Bartness TJ

Your documentation should cover: The specific problem addressed during the visit A medically appropriate history and/or examination, documented to the extent that's clinically relevant Your clinical assessment of the problem The management plan: continuing current treatment, recommending OTC options, providing reassurance, or giving basic follow-up instructions Any data reviewed, such as prior labs or records, including what you found One rule that's worth repeating: under current guidelines, history and examination don't select the code level

Thats because both cancer and its treatment often create one or more of the conditions necessary for blood clot formation

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