They don't have to have separate notes as long as the documentation for both visits is clear within that dictation/note. It would be best if they were documented separately but no rule I know of as of yet that says it's a must.When a physician performs a preventive exam and an office visit on the same day, do they have to have two office notes or can they have one note and try to document the preventive separately from the office visit?
Can I ask who brought this to your attention and is it from an official source. I am asking because our Compliance dept just spoke on this topic.This subject was brought to our attention at our clinic. I am an Assistant Manager for an Internal Medicine Practice. We were just advised that if a patient comes in for a preventative visit and have a problem, the doctor must have the preventative visit on one progress note and the "problem" visit on a different progress. They can be billed on one claim, though.
Chastity Cecil, CPC