procedure note documentation


Marietta, OK
Best answers
I need help finding the requirements for an injection procedure note, especially a joint injection. I have a Family Med provider that is questioning what is "ACTUALLY REQUIRED" for the joint injections eg: knee joint injections. I have stated the following are required components of the procedure note...signed consent, anatomic location, preparation of the site, local anesthetic administration, name and dosage of drug administered and patient's reaction. I sent him the following website ( where is states exactly what I said but he doesn't agree and wants more documentation. Can anyone point me in the right direction?
The CPT book. The 20610/20611 codes live in the "Surgery" section of the CPT book. While they don't have a global other than the day of, they are considered "minor procedures" and require what you stated above. It seems crazy, I get it, but they are considered minor procedures. It's the same as if they did another minor surgical procedure in office. Believe me, I have had this struggle multiple times. What's the volume these are being done in your practice? Have they been reporting an E/M w/ 25 modifier for these? Are you getting audit requests or denials? If so, show them that, money talks. Having a procedure note that stands alone is key.
Here's a link to a MAC showing what is required for procedure documentation. Some is more operative related but the rest is for procedures:
Here's the same MAC with a video (see 1:10) showing exactly what is expected for 20610/20611:
It says "suggested" but it's not just suggested (lol).
Also, med/legal requirements for documentation of minor surgical procedures done in office, such as consent, etc. which you could look up for your state separate from the coding/billing talk. Legal matters.

Also, going hand in hand with needing a procedure "note" is the 25 modifier issue:
If you look up the CPT in the fee schedule lookup tool (CMS) it shows a global of 000. See below for the definition. Meaning, if you are trying to bill an E/M on the same day as the 20610, you would have to append a 25 modifier. The documentation has to support a significant, separately identifable E/M on the same day as a minor procedure (20610).
If you look up minor procedure and global in the CMS manuals:
"C. Minor Surgeries and Endoscopies Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed." "000 = Medicare includes endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only in the fee schedule payment amount. Medicare doesn’t generally pay evaluation and management (E/M) services on the day of the procedure."
Also, the NCCI manual: "If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider/supplier is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. The NCCI program contains many, but not all, possible edits based on these principles."
Don't they want to be sure they are paid for their work? It doesn't have to be a completely separate note, while that it helpful and my best advice, it can live inside the chart note. You want to make sure that both can stand alone should they come under scrutiny.

AAFP reference (old but still true)
Other reference:

"Documentation must substantiate that the E/M service was significant; a best practice is to separate the documentation for the joint injection/aspiration and the E/M service. Only if the E/M service stands on its own may you report it separately with modifier 25."