Results 1 to 3 of 3

Procedure on same day as visit.

  1. #1
    Default Procedure on same day as visit.
    Medical Coding Books
    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?

  2. #2
    its not a requirement, but it certainly make it easier to appeal

  3. #3
    Milwaukee WI
    Default 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

Similar Threads

  1. Home visit and office visit same day, how do I code
    By nelstx2 in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 12-27-2013, 02:31 PM
  2. Billing well visit & sick visit same day
    By lisamgoguen in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 11-13-2013, 01:39 PM
  3. inpatient visit and procedure on same day
    By sjobe in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 06-12-2013, 12:12 PM
  4. Chiro Visit and Family Practice Visit Same Day
    By PeaPod1 in forum Medicare Regulations
    Replies: 2
    Last Post: 09-10-2010, 08:28 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.