• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki EM doc mod 25 and procedure on SDOS

Create Wiki
M

marymartelloni

Guest
Messages
11
Location
Cape Coral, FL
Best answers
0
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
 
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.
 
Last edited:
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
 
You must log in or register to reply here.
Top