Wiki Pain Mgmt Procedure Note Documentation

[LMOuellette]

Hello, I am looking for some guidance. I work in a multi-specialty practice and we have a Pain specialist on staff that does procedures such as epidural, nerve blocks and RAF. My question is, he does not feel as though his notes for these procedures warrant an HPI and ROS b/c he does not add a level of visit to the note. My understanding from school as a standard, all notes should have an HPI and ROS regardless of what service is rendered. Can someone please advise on this and tell me where I can find documentation to support it. Thank you from a frustrated not yet CPC.

 

[AmandaBriggs]

Because these are procedures and not office visits, I agree with the provider that an HPI and ROS are not necessary. The documentation format for a procedure should more closely follow that of an operative note. Here is a link to an AAPC blog that discusses the documentation components of an operative note: https://www.aapc.com/blog/31052-cru...rocedure 8 Indications for Surgery More items

 

[LMOuellette]

The procedures are done in office, not even in a Ambulatory Surgical Center. So would this forum apply?

 

[AmandaBriggs]

Yes, procedures are performed in the office all of the time. They are just a different type of service with their own unique CPT codes. The E/M guidelines don't apply to procedures.

 

[LMOuellette]

Thank you so very much. Now he has more to document.