Patient comes in to the office specifically for cryosurgery of warts. Patient was evaluated for the warts a few weeks prior and scheduled to have the destruction. My question is, should the provider document a problem focused exam on the date of the cryosurgery or is the procedure note sufficient? My feeling is the skin needs to be checked for infections and/or other lesions prior to performing the destruction.
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Wiki in office Preprocedure documentation
- Thread starter PennyG
- Start date
SharonCollachi
Guest
That would be a very minor service and would be included in the destruction. No E&M code/office visit would be billed on the day of the destruction.
thomas7331
Guest
It is not a coding requirement that the physician document an exam on the date of the procedure - the procedure note is sufficient. Whether or not the skin "needs to be checked for infections and/or other lesions" is a clinical decision that is up to the provider - it would not change how the service is coded.