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Wiki Procedure on same day as visit.

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jvalntine

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Could some one clarify if a seperate note needs to be documented for a procedure performed on the same day as a visit.
I have a doc who did an Initial Inpatient Admit, and during the course of the exam did a incision of soft tissue abscess (20000). Should the procedure be documented in a seperate dictation. This doctor documented in the Exam portion of the H & P, and is reporting a mod 25 for the H&P 99223. I requested that he document the procedure in a seperate note. Is this correct?
JV
 
Plan to vs Did

Just make sure that the documentation, whether included in the body of the original note or as a separate note, clearly outlines that the procedure was done.

It seems obvious, but I see a lot of notes (especially in the ER) where the A/P includes something like: "will repair 3cm lac." And they wonder why the repair doesn't get coded. Saying you "will" do something is not the same as documenting that you did it.

I actually suggested that they simply add a paragraph, titled "Procedure note" and outline what was done.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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