Do payers care what kind of note a procedure is on?

[kaylahcm@hotmail.com]

So our system has progress notes, procedure notes, order notes, quick notes.
I have a provider that documents IUD, Nexplanon insertions on progress notes, if we have to submit these notes as is, with IUD insertion being on progress note, will we be flagged?

 

[natashalage]

i am not an expert. here are my thoughts: if you have the description of insertion of IUD, then i would code it ( and i do code it but i am not a biller so i don't' know if we get denials.). The description should not interfere with required documentation for IP E/M code which is billed separately-mod 25.

 

[RCiscoObGyn]

So our system has progress notes, procedure notes, order notes, quick notes.
I have a provider that documents IUD, Nexplanon insertions on progress notes, if we have to submit these notes as is, with IUD insertion being on progress note, will we be flagged?

It's standard practice in most office settings for providers to document small in-office procedures in the same notes as the clinic visit. Typically, from my experience, they only use a separate op note if the patient's procedure was performed in an OR as outpatient or inpatient. The subject lines don't affect billing; they're for internal purposes only. What matters is the actual documentation, and as long as the codes match what the providers documented, it's fine.