EM doc mod 25 and procedure on SDOS

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If a Dr performs a procedure( minor in office procedure) on the SDOS as an EM and appends the EM with Modifier 25, does the procedure note need to be separate from the EM or my the procedure note be in the body of the EM dictation as long as they separate and indentifiable
I can not find anything on CMS if the procedure note can be contained in the body of the EM I need to provide a Written reference to a MD"
Thanks
Mary
 

lphillips

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Anchorage, AK
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re: E/M & procedure

We bill alot of those at our clinic - and the providers dictate/document it all in one note. Sorry, I don't know where you can find something in writing to give to your provider.

The only time they have to do seperate documentation/dictation is if we are billing something like W/C and a regular office visit on the SDOS.
 
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Milwaukee WI
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Some do two dictations

Some of our docs do two dictations, but most just add a paragraph heading: Procedure - XXX, (e.g. Procedure - Chest tube) and then dictate what they did ... it's all one document.

It doesn't have to be a completely separate document, as long as it's clearly defined that the procedure and the E/M were separate.

F Tessa Bartels, CPC, CPC-E/M
 
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