Question ECC performed in office; Is documentation required?

SKE2027

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Good afternoon all! My provider performed an ECC on an Aetna patient in an office setting and had the following question:

"Given the effort for an ECC is the same as a Pap (which we don’t document with a separate note), are we unable to get reimbursed without a separate note?"

I believe the doctor would still need to provide documentation, effort not withstanding, but I cannot find proof. Can someone help me?
 

csperoni

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I don't see any need for a separate note. Somewhere in the record there should be a note of what took place. If you plan on billing for E/M service as well, the 1 note needs to substantiate a distinct visit.
 

SKE2027

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I don't see any need for a separate note. Somewhere in the record there should be a note of what took place. If you plan on billing for E/M service as well, the 1 note needs to substantiate a distinct visit.
Here is the HPI and A/P:

History of Present Illness
56-year old woman G4P2 seen last week due to complaints of menses q 2 weeks. She was evaluated in 2020 for menorrhagia and EMB at that time showed proliferative endometrium and a benign polyp. Her Pap on 10/14/21 showed AGC as well as normal endometrial cells and HPV HR was negative. EMB showed markedly fragmented benign endometrial tissue with extensive breakdown that limited evaluation. TVS 10/21 showed an 8cm uterus with small intramural and subserosal myomas with evidence of adenomyosis. The endometrium was normal in thickness with no focal abnormalities. On 10/28/21 she underwent colposcopy and office hysteroscopy. The former was non-satisfactory but free of lesions and the latter showed no foal abnormalities. Pathology results are as follows:

A. Endocervix (curettage):
Predominantly blood and mucus.
Tissue insufficient for diagnosis.

B. Cervix, 6 o'clock (biopsy): Grossly consistent with a nabothian cyst
Predominantly mucus.
Rare fragments of benign endocervical glands.

A. Endometrium (biopsy):
Scant fragments of benign endometrial tissue with features suggestive of polyp.

She returns for repeat ECC given the non diagnostic findings.


Assessment & Plan
56 year old perimenopausal woman with abnormal uterine bleeding and recent AGC on pap. Recent EMB and hysteroscopy negative. Cervical colpo was non-satisfactory but free of AWE or abnl vasculature. ECC repeated today due to non-diagnostic results


1. F/U repeat ECC
2. If no evidence of pathology, no need for further testing or treatment. Will repeat Pap in 6 months
 

nielynco

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Good afternoon all! My provider performed an ECC on an Aetna patient in an office setting and had the following question:

"Given the effort for an ECC is the same as a Pap (which we don’t document with a separate note), are we unable to get reimbursed without a separate note?"

I believe the doctor would still need to provide documentation, effort not withstanding, but I cannot find proof. Can someone help me?
You probably won't find it in writing, but to me, it seems important to document any invasive procedure from a risk perspective. An ECC may not be much work, but it more invasive than a Pap smear and for that reason you might want to create a template that can be used and inserted into the note. It would also be important to note that the patient had no bleeding and left the office in good condition with no complaints.
 
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