Primary Care Coding Alert

Question: In our office, we usually use one note to describe a procedure and an E/M. Why do experts recommend that we write separate notes?

Ohio Subscriber

Answer: Readability is the basic reason that documenting separate procedure and E/M service notes is important. If you combine both into one, the E/M service gets buried. In the event of an appeal, the documentation will offer a weak case.
 
Paper-saver: Separate notes do not require separate sheets. You just need to write separate paragraphs -- one for the procedure and one describing the E/M service.
 
Example: See how easy it is to identify the E/M service from the procedure in the following two-paragraph encounter:
   
The patient is here for the influenza vaccine. Mother reports a cough for several days without any fever. She is eating well and there has been no wheezing or rapid breathing. Her temperature is 98.7-F and respiratory rate is 38/minute -- she appears well. The symptomatic treatment of the cough per protocol was discussed, and the mother was instructed to call or return if the problem worsened.
   
She has no allergies to foods or history of reactions to past vaccines. The risks and potential side effects of the hepatitis B vaccine were discussed after the VIS was given, and the mother was informed of the correct dosage of an antipyretic should fever or fussiness occur afterward. An influenza vaccine was given. (The nurse records the actual vaccine data with lot number and site/route and VIS date on a separate immunization record.)

If a payer denies the E/M service, the above documentation makes a solid case for appeal. Highlight or circle the first paragraph describing the E/M service (99211-25, Office or other outpatient visit for the E/M of an established patient -; significant, separately identifiable E/M service by the same physician on the same day of the procedure or another service) as significant and separately identifiable from the vaccine administration (90471, Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for influenza (90657, Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use).
 
Point out that the separate diagnoses -- 786.2 for cough (99211-25), and V04.81 (Need for prophylactic vaccination and inoculation against certain viral diseases; other viral diseases; influenza) for the immunization administration (90471) and vaccine (90657) -- confirm that the E/M service meets the modifier 25 criteria and warrants payment.

 -- Answers to You Be the Coder and Reader Questions reviewed/provided by Jim Collins, CPC, CHCC, president of Compliant MD Inc.; Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City; Victoria S. Jackson, practice management consultant with JCM Inc. in California; and Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.