Procedure code - It was written by the surgeon, not the ER doctor, and if the surgeon just happened to be the ER doctor, the E/M portion would have become part of the global surgical package, anyways. When notes are in the format you gave, they are generally going to be for surgical procedures. You can only bill an E/M code with a procedure done by the same doctor on the same day, if a significant and separately identifiable problem was addressed. The notes must make it clear that the doctor went above and beyond the usual pre-service and post-service work associated with the procedure. If you get some free time, read all of the green pages in your CPT book, especially those for E/M and surgery. Those guidelines are extremely important to your success. Hope that helps!
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